Provider Demographics
NPI:1790899284
Name:PRIDE COUNSELING INC
Entity Type:Organization
Organization Name:PRIDE COUNSELING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BUIE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-595-0666
Mailing Address - Street 1:1174 E GRAYSTONE WAY STE 20E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2678
Mailing Address - Country:US
Mailing Address - Phone:801-595-0666
Mailing Address - Fax:801-595-0669
Practice Address - Street 1:1174 E GRAYSTONE WAY STE 20E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2678
Practice Address - Country:US
Practice Address - Phone:801-595-0666
Practice Address - Fax:801-595-0669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT140182-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT377869655001Medicaid
UT37786965502001OtherBCBS OF UTAH
UT000057935Medicare PIN
UT005793501Medicare ID - Type UnspecifiedFOR JERRY BUIE