NPI | 1063833721 |
---|---|
Former Legal Business Name | THETA WELLNESS CENTER - PROVO |
Entity Type | Organization |
Authorized Contact | KENDRA BERNAL Clinical Administrator 801-869-8199 |
Organization Subpart ? | No |
Primary Taxonomy | 261Q00000X Clinic/Center |
Additional Taxonomies | 261QH0100X Clinic/Center Health Service (Licence: UT NOT REQUIRED) |
261QH0100X Clinic/Center Health Service (Licence: UT 0000000) | |
261QM0850X Clinic/Center Adult Mental Health (Licence: UT NOT REQUIRED) | |
261QM0850X Clinic/Center Adult Mental Health (Licence: UT 00000000000) | |
261QM0855X Clinic/Center Adolescent and Children Mental Health (Licence: UT NOT REQUIRED) | |
Enumeration Date | 2013-12-26 |
Last Update Date | 2014-04-09 |