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General NPI Number Information
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NPI Number | 1568510550
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Entity Type | Organization
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Legal Business Name | FAMILY SUPPORT CENTER
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Dates
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Enumeration Date | 01/08/2007
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Last Update Date | 06/20/2011
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Provider Practice Location Address
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Address Line | 777 W CENTER ST
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City | MIDVALE
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State | UT
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Zip | 84047-7148
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Country | US
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Telephone | 801-955-9411
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Fax | 801-955-9411
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Provider Business Mailing Address
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Address Line | 1760 W 4805 S
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City | TAYLORSVILLE
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State | UT
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Zip | 84118-1177
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Country | US
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Telephone | 801-955-9110
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Fax | 801-955-9411
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | MR. PAUL M. RICKS
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Credential | LCSW
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Telephone | 801-955-9110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 17474
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 12358
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License Number State | UT
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