Provider Demographics
NPI:1669762506
Name:ABC-ADVANCED BEHAVIORAL COUNSELING, LLC
Entity type:Organization
Organization Name:ABC-ADVANCED BEHAVIORAL COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:GALWAY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:801-915-1290
Mailing Address - Street 1:3200 S 600 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-1218
Mailing Address - Country:US
Mailing Address - Phone:801-915-1290
Mailing Address - Fax:
Practice Address - Street 1:997 E 3900 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1108
Practice Address - Country:US
Practice Address - Phone:801-915-1290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT17766251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health