Basic Information
| Provider Information | |||||||||
| NPI: | 1154381192 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SILVERADO COUNSELING SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 521207 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841521207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019835540 | ||||||||
| FaxNumber: | 8019835542 | ||||||||
| Practice Location | |||||||||
| Address1: | 3195 S MAIN ST STE 180 | ||||||||
| Address2: | |||||||||
| City: | SOUTH SALT LAKE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841153790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019835540 | ||||||||
| FaxNumber: | 8019835542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
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| AuthorizedOfficialLastName: | WEISBENDER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 8019835540 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 10/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 175T00000X | N | 193200000X MULTI-SPECIALTY GROUP | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 788007788802 | 05 | UT | MEDICAID | 777003861000 | 05 | UT | MEDICAID |