MEDICARE: OPTIMAL SELF 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	1041C0700X	Clinical Social Worker
3	251S00000X	Community/Behavioral Health Agency
4	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1932833456
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMAL SELF LLC

Provider Business Mailing Address
First Line	:	251 S MOUNTAIN RD STE 1
Second Line	:
City	:	FRUIT HEIGHTS
State	:	UT
Zip	:	84037-2371
Country	:	US
Telephone Number	:	801-643-2030
Fax Number	:

Provider Business Practice Location Address
First Line	:	251 S MOUNTAIN RD STE 1
Second Line	:
City	:	FRUIT HEIGHTS
State	:	UT
Zip	:	84037-2371
Country	:	US
Telephone Number	:	385-381-4950
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TYLER FARNES
Credential	:
Telephone Number	:	801-231-5942

Provider Enumeration Date	:	07/11/2022
Last Update Date	:	05/20/2024

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