=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639537632
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A COURAGEOUS LIFE COUNSELING, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2016
-----------------------------------------------------
Last Update Date | 02/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3409 W 12600 S STE 230
-----------------------------------------------------
City | RIVERTON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84065-7270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-248-2325
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3409 W 12600 S STE 230
-----------------------------------------------------
City | RIVERTON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84065-7270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-248-2325
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | JULIA SICKLES
-----------------------------------------------------
Credential | L.C.S.W.
-----------------------------------------------------
Telephone | 435-248-2325
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 9452890-3501
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------