Provider Demographics
NPI:1164398392
Name:BROOKSIDE WELLNESS CENTER PLLC
Entity type:Organization
Organization Name:BROOKSIDE WELLNESS CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:COLBY
Authorized Official - Middle Name:GANNON
Authorized Official - Last Name:BACKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CMHC
Authorized Official - Phone:435-429-1042
Mailing Address - Street 1:4688 S WALLACE DR UNIT G
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-1863
Mailing Address - Country:US
Mailing Address - Phone:435-429-1042
Mailing Address - Fax:
Practice Address - Street 1:4688 S WALLACE DR UNIT G
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-1863
Practice Address - Country:US
Practice Address - Phone:435-429-1042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-14
Last Update Date:2025-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101200000XBehavioral Health & Social Service ProvidersDrama TherapistGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty