Provider Demographics
NPI:1194271601
Name:KEYSTONE FAMILY COUNSELING, PLLC
Entity type:Organization
Organization Name:KEYSTONE FAMILY COUNSELING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEGG
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-380-9305
Mailing Address - Street 1:1172 E 100 N
Mailing Address - Street 2:SUITE 8
Mailing Address - City:PAYSON
Mailing Address - State:UT
Mailing Address - Zip Code:84651-1667
Mailing Address - Country:US
Mailing Address - Phone:801-380-9305
Mailing Address - Fax:
Practice Address - Street 1:1172 E 100 N
Practice Address - Street 2:SUITE 8
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-1667
Practice Address - Country:US
Practice Address - Phone:801-380-9305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-25
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7442576-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty