Provider Demographics
NPI:1467601492
Name:PRIMARY CHILDREN'S CENTER FOR COUNSELING
Entity Type:Organization
Organization Name:PRIMARY CHILDREN'S CENTER FOR COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PCCC
Authorized Official - Prefix:PROF
Authorized Official - First Name:DORANN
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-265-3000
Mailing Address - Street 1:5770 S 1500 W
Mailing Address - Street 2:#G
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5216
Mailing Address - Country:US
Mailing Address - Phone:801-265-3000
Mailing Address - Fax:801-265-3025
Practice Address - Street 1:5770 S 1500 W
Practice Address - Street 2:#G
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84123-5216
Practice Address - Country:US
Practice Address - Phone:801-265-3000
Practice Address - Fax:801-265-3025
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTERMOUNTAIN HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-15
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT380804-3501251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health