MEDICARE: PIVOTAL TRAUMA COUNSELING LLC

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

General Provider Information

NPI Number	:	1790438745
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PIVOTAL TRAUMA COUNSELING LLC

Provider Business Mailing Address
First Line	:	10982 S MAPLE FOREST WAY
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84095-4120
Country	:	US
Telephone Number	:	801-406-1145
Fax Number	:

Provider Business Practice Location Address
First Line	:	489 W SOUTH JORDAN PKWY STE 200
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84095-3980
Country	:	US
Telephone Number	:	801-406-1145
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KORILYNN C BARTLEY
Credential	:	CMHC, NCC
Telephone Number	:	801-406-1145

Provider Enumeration Date	:	01/31/2022
Last Update Date	:	01/31/2022

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