MEDICARE: AUTHENTICITY UTAH PLLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1477175560
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUTHENTICITY UTAH PLLC

Provider Business Mailing Address
First Line	:	2265 S STATE ST APT 272
Second Line	:
City	:	SOUTH SALT LAKE
State	:	UT
Zip	:	84115-1405
Country	:	US
Telephone Number	:	435-720-8338
Fax Number	:

Provider Business Practice Location Address
First Line	:	2265 S STATE ST APT 272
Second Line	:
City	:	SOUTH SALT LAKE
State	:	UT
Zip	:	84115-1405
Country	:	US
Telephone Number	:	435-720-8338
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER
Name	:	PETER BRYAN CONDER
Credential	:	LCMHC
Telephone Number	:	435-720-8338

Provider Enumeration Date	:	05/11/2020
Last Update Date	:	05/11/2020

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