Provider Demographics
NPI:1417664897
Name:SAGE CANYON COUNSELING, PLLC
Entity Type:Organization
Organization Name:SAGE CANYON COUNSELING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAMON
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:970-403-2458
Mailing Address - Street 1:1291 W ATHERTON DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-2478
Mailing Address - Country:US
Mailing Address - Phone:406-861-2288
Mailing Address - Fax:
Practice Address - Street 1:2290 E 4500 S STE 180
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-4493
Practice Address - Country:US
Practice Address - Phone:970-403-2458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)