MEDICARE: BORAGE WELLNESS CENTER

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1316638117
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BORAGE WELLNESS CENTER

Provider Business Mailing Address
First Line	:	4646 S 3500 W STE 2
Second Line	:
City	:	WEST HAVEN
State	:	UT
Zip	:	84401-9405
Country	:	US
Telephone Number	:	801-719-9410
Fax Number	:

Provider Business Practice Location Address
First Line	:	4646 S 3500 W STE 2
Second Line	:
City	:	WEST HAVEN
State	:	UT
Zip	:	84401-9405
Country	:	US
Telephone Number	:	801-719-9410
Fax Number	:

Authorized Official
Title or Position	:	OWNER, CLINICIAN
Name	:	ABREE SEPULVEDA MIZE
Credential	:	LCSW
Telephone Number	:	801-719-9410

Provider Enumeration Date	:	05/15/2023
Last Update Date	:	07/03/2024

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Directions to “BORAGE WELLNESS CENTER ” Practice Location

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