Basic Information
| Provider Information | |||||||||
| NPI: | 1760810337 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERMOUNTAIN HEALTHCARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 324 E 10TH AVE STE 178 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841032885 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 324 E 10TH AVE STE 178 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841032885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014088500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2013 | ||||||||
| LastUpdateDate: | 10/17/2013 | ||||||||
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| AuthorizedOfficialLastName: | MIRIN | ||||||||
| AuthorizedOfficialFirstName: | GUDRUN | ||||||||
| AuthorizedOfficialMiddleName: | ULRIKE | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL SOCIAL WORKER | ||||||||
| AuthorizedOfficialTelephone: | 8014088500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | 932611213501 | UT | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.