Provider Demographics
NPI:1750806519
Name:SUNDANCE CANYON THERAPY, COACHING, AND CONSULTING
Entity type:Organization
Organization Name:SUNDANCE CANYON THERAPY, COACHING, AND CONSULTING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:801-678-4198
Mailing Address - Street 1:4832 W FIRMONT DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009-8291
Mailing Address - Country:US
Mailing Address - Phone:801-678-4198
Mailing Address - Fax:
Practice Address - Street 1:180 N UNIVERSITY AVE STE 270
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-5648
Practice Address - Country:US
Practice Address - Phone:801-678-4198
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-13
Last Update Date:2017-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10471569-0160261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)