Provider Demographics
NPI:1245729417
Name:MOMENTUM COUNSELING SERVICES, CORP
Entity type:Organization
Organization Name:MOMENTUM COUNSELING SERVICES, CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:801-518-9362
Mailing Address - Street 1:1446 E ANVIL DR
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8832
Mailing Address - Country:US
Mailing Address - Phone:801-898-7502
Mailing Address - Fax:
Practice Address - Street 1:11075 S STATE ST STE 13
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-5193
Practice Address - Country:US
Practice Address - Phone:801-948-0939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6153954-3902106H00000X
UT8598755-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty