=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649901984
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COURAGE MOUNTAIN COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2022
-----------------------------------------------------
Last Update Date | 06/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28 S 850 E
-----------------------------------------------------
City | PLEASANT GROVE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84062-4516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-736-0889
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28 S 850 E
-----------------------------------------------------
City | PLEASANT GROVE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84062-4516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-736-0889
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / ADMINISTRATIVE DIRECTOR
-----------------------------------------------------
Name | WENDY VINCENT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 801-736-0889
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------