| Full Name | |
|---|---|
| Speciality | Community/behavioral Health |
| Location | 50 N Main St, Tooele, Utah |
| Authorized Official Name and Position | Evan T Kenison (MENTAL HEALTH THERAPIST) |
| Authorized Official Contact | 4358502547 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 751 Tooele UT 84074-0751 Ph: (435) 850-2547 | 50 N Main St Tooele UT 84074-2139 Ph: (435) 485-0254 |
| NPI Number | 1639312382 |
|---|---|
| Provider Enumeration Date | 04/10/2009 |
| Last Update Date | 04/10/2009 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1639312382 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | 3099283501 (Utah) | Primary |
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