Healthcare Provider Details

I. General information

NPI: 1235848599
Provider Name (Legal Business Name): INTELLIGENT CHILDREN UNDERRATED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 S 1000 E APT 1302
CLEARFIELD UT
84015-1663
US

IV. Provider business mailing address

1550 S 1000 E APT 1302
CLEARFIELD UT
84015-1663
US

V. Phone/Fax

Practice location:
  • Phone: 443-845-9858
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name: TRE JAMES
Title or Position: CEO/PROGRAM DIRECTOR
Credential:
Phone: 385-456-6275