MEDICARE: FUNCTIONALLY INTEGRATIVE THERAPY LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1184503492
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUNCTIONALLY INTEGRATIVE THERAPY LLC

Provider Business Mailing Address
First Line	:	PO BOX 18182
Second Line	:
City	:	KEARNS
State	:	UT
Zip	:	84118-0182
Country	:	US
Telephone Number	:	385-208-6197
Fax Number	:

Provider Business Practice Location Address
First Line	:	5620 S WATERBURY WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-1180
Country	:	US
Telephone Number	:	385-208-6197
Fax Number	:

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	STEVEN ROTH
Credential	:	LCSW
Telephone Number	:	385-208-6197

Provider Enumeration Date	:	08/29/2025
Last Update Date	:	08/29/2025

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