=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528534401
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEAR CREEK COUNSELING,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2018
-----------------------------------------------------
Last Update Date | 08/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1227 W 9000 S STE H
-----------------------------------------------------
City | WEST JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84088-9001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 385-274-7119
-----------------------------------------------------
Fax | 385-257-8880
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1227 W 9000 S STE H
-----------------------------------------------------
City | WEST JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84088-9001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 385-274-7119
-----------------------------------------------------
Fax | 385-257-8880
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PATRICIA COX
-----------------------------------------------------
Credential | CMHC
-----------------------------------------------------
Telephone | 801-834-3276
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------