Basic Information
| Provider Information | |||||||||
| NPI: | 1053864066 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GHANE | ||||||||
| FirstName: | TAKAVAR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 747 E SAINT GEORGE BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847703035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356736111 | ||||||||
| FaxNumber: | 4356730994 | ||||||||
| Practice Location | |||||||||
| Address1: | 747 E SAINT GEORGE BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847703035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356736111 | ||||||||
| FaxNumber: | 4356730994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2016 | ||||||||
| LastUpdateDate: | 07/26/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6782719-6004 | UT | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.