Provider Demographics
NPI:1053910331
Name:MOUNT OLYMPUS COUNSELING CENTER, INC.
Entity type:Organization
Organization Name:MOUNT OLYMPUS COUNSELING CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, LCMHC
Authorized Official - Phone:801-792-7028
Mailing Address - Street 1:4525 S 2300 E STE 102
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4682
Mailing Address - Country:US
Mailing Address - Phone:801-860-7818
Mailing Address - Fax:
Practice Address - Street 1:4525 S 2300 E STE 102
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-4682
Practice Address - Country:US
Practice Address - Phone:801-860-7818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty