1760037675 NPI number — INTEGRATED PSYCHOTHERAPY SERVICES

Table of content: (NPI 1760037675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760037675 NPI number — INTEGRATED PSYCHOTHERAPY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATED PSYCHOTHERAPY SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760037675
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 508
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84110-0508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-520-7938
Provider Business Mailing Address Fax Number:
800-528-1208

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
352 S DENVER ST STE 315
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84111-3054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-520-7938
Provider Business Practice Location Address Fax Number:
800-528-1208
Provider Enumeration Date:
08/07/2019

Additional Information

Authorized Official

Authorized Official Last Name:
GOUVEIA-GRANT
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
CLINICIAN
Authorized Official Telephone Number:
801-520-7938

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1790125730 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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