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General NPI Number Information
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NPI Number | 1558611970
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Entity Type | Organization
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Legal Business Name | NEW LIFE BALANCE, LLC
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Dates
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Enumeration Date | 09/13/2012
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Last Update Date | 09/13/2012
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Provider Practice Location Address
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Address Line | 2689 S HIGHLAND DR
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City | SALT LAKE CITY
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State | UT
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Zip | 84106-2774
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Country | US
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Telephone | 435-695-4421
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Fax | 385-259-0990
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Provider Business Mailing Address
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Address Line | 2689 S HIGHLAND DR
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City | SALT LAKE CITY
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State | UT
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Zip | 84106-2774
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Country | US
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Telephone | 435-695-4421
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Fax | 385-259-0990
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Authorized Official
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Title or Position | REGISTERED AGENT
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Name | CHARLES MCCUSKER
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Credential |
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Telephone | 435-695-4421
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1160352501
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License Number State | UT
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