Provider Demographics
NPI:1992467963
Name:PROVO COUNSELING CENTER
Entity Type:Organization
Organization Name:PROVO COUNSELING CENTER
Other - Org Name:PROVO COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:CORY
Authorized Official - Middle Name:BRAD
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHC LCSW
Authorized Official - Phone:801-472-7134
Mailing Address - Street 1:3325 N UNIVERSITY AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-7412
Mailing Address - Country:US
Mailing Address - Phone:801-472-7134
Mailing Address - Fax:801-743-7599
Practice Address - Street 1:3325 N UNIVERSITY AVE STE 300
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-7412
Practice Address - Country:US
Practice Address - Phone:801-472-7134
Practice Address - Fax:801-743-7599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-07
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1992467963Medicaid