Provider Demographics
NPI:1225254956
Name:CHOICEPOINT THERAPEUTIC SERVICES, LLC
Entity Type:Organization
Organization Name:CHOICEPOINT THERAPEUTIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:M.
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:GOURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:JD, LCSW, MFT
Authorized Official - Phone:801-983-5700
Mailing Address - Street 1:1390 S 1100 E
Mailing Address - Street 2:STE 203
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2461
Mailing Address - Country:US
Mailing Address - Phone:801-983-5700
Mailing Address - Fax:
Practice Address - Street 1:1390 S 1100 E
Practice Address - Street 2:STE 203
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-2461
Practice Address - Country:US
Practice Address - Phone:801-983-5700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12126251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health