# BROOKSIDE WELLNESS CENTER PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1164398392
- **Authorized official:** COLBY GANNON BACKMAN CMHC (PROGRAM DIRECTOR)
- **Authorized official phone:** (435) 429-1042

## Contact information

- **Practice address:** 4688 S WALLACE DR UNIT G, SAINT GEORGE, UT 84790-1863
- **Practice address phone:** (435) 429-1042
- **Mailing address:** 4688 S WALLACE DR UNIT G, SAINT GEORGE, UT 84790-1863
- **Mailing address phone:** (435) 429-1042

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 101200000X | Drama Therapist | — | NULL | — |
| 101200000X | Drama Therapist | — | — | — |
| 101Y00000X | Counselor | — | NULL | — |
| 101Y00000X | Counselor | — | — | — |
| 101YM0800X | Mental Health Counselor | — | NULL | Yes |
| 101YM0800X | Mental Health Counselor | — | — | Yes |

## Other

- **Enumeration date:** 10/14/2025
- **Last updated:** 10/14/2025