Basic Information
| Provider Information | |||||||||
| NPI: | 1851016380 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | ANGELA | ||||||||
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| Credential: | CFLE-P | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2765 S 1200 W | ||||||||
| Address2: | |||||||||
| City: | PERRY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843024224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357401490 | ||||||||
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| Practice Location | |||||||||
| Address1: | 585 W 500 S STE 200 | ||||||||
| Address2: | |||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840108321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019904300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2022 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | UT | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.