MEDICARE: ORIGINAL THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	106H00000X	Marriage & Family Therapist
3	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1083430011
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORIGINAL THERAPY LLC

Provider Business Mailing Address
First Line	:	1067 E WOOD AVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-2411
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	455 E 200 S STE 110
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-2156
Country	:	US
Telephone Number	:	435-994-9259
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DIRECTOR
Name	:	TONYA LUNDAHL
Credential	:	LCSW
Telephone Number	:	435-994-9259

Provider Enumeration Date	:	11/25/2024
Last Update Date	:	11/25/2024

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