Basic Information
| Provider Information | |||||||||
| NPI: | 1558478677 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAIN LAND FAMILY THERAPY CLINICS LC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 711185 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019423311 | ||||||||
| FaxNumber: | 8019425955 | ||||||||
| Practice Location | |||||||||
| Address1: | 3570 W 9000 S | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | W JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840888874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015618888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8019423311 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.