| 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 |