Provider Demographics
NPI:1811319502
Name:JOURNEY COUNSELING CENTER PROVO LLC
Entity type:Organization
Organization Name:JOURNEY COUNSELING CENTER PROVO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QUALITY ASSURANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-785-0465
Mailing Address - Street 1:619 N 500 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1547
Mailing Address - Country:US
Mailing Address - Phone:801-375-4240
Mailing Address - Fax:801-375-4241
Practice Address - Street 1:619 N 500 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1547
Practice Address - Country:US
Practice Address - Phone:801-375-4240
Practice Address - Fax:801-375-4241
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE JOURNEY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-14
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT20850253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency