MEDICARE: ST. JOHN THERAPEUTIC SERVICES INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	264211-3501	UT
2	101YM0800X	Mental Health Counselor	1437121357	UT

General Provider Information

NPI Number	:	1104078229
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. JOHN THERAPEUTIC SERVICES INC.

Provider Business Mailing Address
First Line	:	555 E 5300 S
Second Line	:	SUITE 6
City	:	SOUTH OGDEN
State	:	UT
Zip	:	84405-4509
Country	:	US
Telephone Number	:	801-621-5385
Fax Number	:

Provider Business Practice Location Address
First Line	:	555 E 5300 S
Second Line	:	SUITE 6
City	:	SOUTH OGDEN
State	:	UT
Zip	:	84405-4509
Country	:	US
Telephone Number	:	801-621-5385
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. FRANK J MERCIK
Credential	:
Telephone Number	:	801-621-5385

Provider Enumeration Date	:	10/21/2008
Last Update Date	:	10/21/2008

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