=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518407964
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLOURISH COUNSELING SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2017
-----------------------------------------------------
Last Update Date | 03/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 91 W 200 S
-----------------------------------------------------
City | PROVO
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84601-4443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-400-2569
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1031 S 1130 W
-----------------------------------------------------
City | PAYSON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84651-9603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-400-2569
-----------------------------------------------------
Fax | 801-465-1917
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | LISA TENSMEYER HANSEN
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 801-400-2569
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 4859896-3902
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------