Basic Information
| Provider Information | |||||||||
| NPI: | 1548745979 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 FOOTHILL DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015821565 | ||||||||
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| Practice Location | |||||||||
| Address1: | 50 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TOOELE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840742139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019904300 | ||||||||
| FaxNumber: | 8019672127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2018 | ||||||||
| LastUpdateDate: | 05/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 10706801-3501 | UT | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.