Basic Information
| Provider Information | |||||||||
| NPI: | 1336370907 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROMERO | ||||||||
| FirstName: | GALEN | ||||||||
| MiddleName: | RONNIE | ||||||||
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| Credential: | CMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 460 | ||||||||
| Address2: | |||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840110460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012983446 | ||||||||
| FaxNumber: | 8012983449 | ||||||||
| Practice Location | |||||||||
| Address1: | 811 N HARRISVILLE RD | ||||||||
| Address2: | |||||||||
| City: | HARRISVILLE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844043537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013991818 | ||||||||
| FaxNumber: | 8017828412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2009 | ||||||||
| LastUpdateDate: | 08/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 364777-6009 | UT | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1336370907 | 05 | UT | MEDICAID |