Provider Demographics
NPI:1114277001
Name:CIRCLE OF LIFE COUNSELING CENTER, LLC
Entity Type:Organization
Organization Name:CIRCLE OF LIFE COUNSELING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:REALL
Authorized Official - Suffix:
Authorized Official - Credentials:MED, CMHC
Authorized Official - Phone:801-331-6775
Mailing Address - Street 1:3375 MAYFLOWER WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-3134
Mailing Address - Country:US
Mailing Address - Phone:801-331-6775
Mailing Address - Fax:801-766-2010
Practice Address - Street 1:3375 MAYFLOWER WAY
Practice Address - Street 2:SUITE A
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-3134
Practice Address - Country:US
Practice Address - Phone:801-331-6775
Practice Address - Fax:801-766-2010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-18
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT139247-6004101YP2500X
UT6819342-6004101YP2500X
UT5172018-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty