Provider Demographics
NPI:1437885266
Name:GREEN CANYON COUNSELING
Entity Type:Organization
Organization Name:GREEN CANYON COUNSELING
Other - Org Name:SAMUEL POND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:POND
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:435-764-6312
Mailing Address - Street 1:2027 N 200 E
Mailing Address - Street 2:
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-5505
Mailing Address - Country:US
Mailing Address - Phone:435-764-6312
Mailing Address - Fax:
Practice Address - Street 1:2027 N 200 E
Practice Address - Street 2:
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-5505
Practice Address - Country:US
Practice Address - Phone:435-764-6312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-25
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)