Provider Demographics
NPI:1346883634
Name:DREAM RIVER COUNSELING LLC
Entity Type:Organization
Organization Name:DREAM RIVER COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:STILES
Authorized Official - Last Name:RANDAK
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:801-450-0199
Mailing Address - Street 1:PO BOX 900785
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84090-0785
Mailing Address - Country:US
Mailing Address - Phone:801-450-0199
Mailing Address - Fax:888-503-2513
Practice Address - Street 1:850 E 9400 S STE 103
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-4104
Practice Address - Country:US
Practice Address - Phone:801-450-0199
Practice Address - Fax:888-503-2513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-20
Last Update Date:2019-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)