MEDICARE: SIMPLE MODERN THERAPY, 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	106H00000X	Marriage & Family Therapist	67841063902	UT

General Provider Information

NPI Number	:	1821411133
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIMPLE MODERN THERAPY, PLLC

Provider Business Mailing Address
First Line	:	835 E 600 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-2908
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1104 E ASHTON AVE
Second Line	:	212
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-4504
Country	:	US
Telephone Number	:	435-730-2973
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. HEATHER HOLMGREN
Credential	:	LMFT
Telephone Number	:	435-730-2973

Provider Enumeration Date	:	01/23/2014
Last Update Date	:	01/23/2014

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