=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902239379
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UTAH COUNSELING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2013
-----------------------------------------------------
Last Update Date | 08/20/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 189 S STATE ST SUITE 230
-----------------------------------------------------
City | CLEARFIELD
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84015-1061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-589-0819
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3542 GREY CROWN CRANE LN
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84015-6100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HEATHER POTOKAR
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 801-589-0819
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 3083240-3501
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------