1013478346 NPI number — KINTSUGI COUNSELING, LLC

Table of content: (NPI 1013478346)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013478346 NPI number — KINTSUGI COUNSELING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KINTSUGI COUNSELING, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013478346
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
520 N MAIN STREET
Provider Second Line Business Mailing Address:
SUITE C#448
Provider Business Mailing Address City Name:
HEBER CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-850-7402
Provider Business Mailing Address Fax Number:
435-538-7000

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 N MAIN ST STE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HEBER CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84032-1671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-850-7402
Provider Business Practice Location Address Fax Number:
435-538-7000
Provider Enumeration Date:
03/28/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EVANS-MCALISTER
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
Authorized Official Title or Position:
MENTAL HEALTH THERAPIST
Authorized Official Telephone Number:
435-850-7402

Provider Taxonomy Codes

  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9056683-6004 . This is a "STATE LICENSE FOR PRACTICE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".