Provider Demographics
NPI:1639506447
Name:JOURNEY COUNSELING CENTER SALT LAKE LLC
Entity Type:Organization
Organization Name:JOURNEY COUNSELING CENTER SALT LAKE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-420-0465
Mailing Address - Street 1:619 N 500 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1547
Mailing Address - Country:US
Mailing Address - Phone:801-375-4240
Mailing Address - Fax:801-375-4041
Practice Address - Street 1:741 E 9000 S
Practice Address - Street 2:STE 100
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3085
Practice Address - Country:US
Practice Address - Phone:801-566-1473
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE JOURNEY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-11
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT20848253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency