MEDICARE: GRACE FORSYTHE PHD INC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	2189134405	UT

General Provider Information

NPI Number	:	1558430389
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE FORSYTHE PHD INC

Provider Business Mailing Address
First Line	:	4271 NEPTUNE DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-3362
Country	:	US
Telephone Number	:	801-273-7769
Fax Number	:	801-273-4073

Provider Business Practice Location Address
First Line	:	2046 MURRAY HOLLADAY RD
Second Line	:	103
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-5125
Country	:	US
Telephone Number	:	801-273-7769
Fax Number	:	801-273-4073

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GRACE A FORSYTHE
Credential	:	PHD, APRN
Telephone Number	:	801-273-7769

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	12/31/2010

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