Provider Demographics
NPI:1821395633
Name:LEGACY COUNSELING CENTER
Entity Type:Organization
Organization Name:LEGACY COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GAWRYS
Authorized Official - Suffix:JR
Authorized Official - Credentials:LPC
Authorized Official - Phone:801-822-4892
Mailing Address - Street 1:318 RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:UT
Mailing Address - Zip Code:84004-2602
Mailing Address - Country:US
Mailing Address - Phone:801-822-4892
Mailing Address - Fax:
Practice Address - Street 1:318 RIDGE DR
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:UT
Practice Address - Zip Code:84004-2602
Practice Address - Country:US
Practice Address - Phone:801-822-4892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT53747966004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty