Provider Demographics
NPI:1821554049
Name:MT GROVE COUNSELING LLC
Entity type:Organization
Organization Name:MT GROVE COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRUNER
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:801-636-3036
Mailing Address - Street 1:66 E STATE RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-2637
Mailing Address - Country:US
Mailing Address - Phone:801-404-0064
Mailing Address - Fax:
Practice Address - Street 1:66 E STATE RD
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-2637
Practice Address - Country:US
Practice Address - Phone:801-404-0064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-12
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1922523281OtherNPI
1386116770OtherNPI