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General NPI Number Information
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NPI Number | 1801518063
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Entity Type | Organization
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Legal Business Name | LITTLE BLACK CAT COUNSELING AND HEALING
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Dates
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Enumeration Date | 09/14/2022
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Last Update Date | 09/14/2022
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Provider Practice Location Address
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Address Line | 715 E 3900 S STE 103
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City | SALT LAKE CITY
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State | UT
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Zip | 84107-2570
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Country | US
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Telephone | 385-377-5995
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Fax |
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Provider Business Mailing Address
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Address Line | 715 E 3900 S STE 103
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City | SALT LAKE CITY
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State | UT
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Zip | 84107-2570
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Country | US
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Telephone | 385-377-5995
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. NICOLE IRENE MEDINA
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Credential | PSYD
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Telephone | 385-377-5995
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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