Provider Demographics
NPI:1295019024
Name:SUNDANCE COUNSELING LLC
Entity Type:Organization
Organization Name:SUNDANCE COUNSELING LLC
Other - Org Name:SUNDANCE COUNSELING LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE PROPREITOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:KILPATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-649-3617
Mailing Address - Street 1:700 BITNER RD STE 105
Mailing Address - Street 2:PO BOX 980901
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-5489
Mailing Address - Country:US
Mailing Address - Phone:435-649-3617
Mailing Address - Fax:435-649-9687
Practice Address - Street 1:700 BITNER RD STE 105
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-5489
Practice Address - Country:US
Practice Address - Phone:435-649-3617
Practice Address - Fax:435-649-9687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8106626-3501251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health