Healthcare Provider Details

I. General information

NPI: 1326783689
Provider Name (Legal Business Name): EVIDENCE BASED TREATMENT CENTERS OF SALT LAKE CITY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 02/02/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 E MURRAY HOLLADAY RD STE 116
HOLLADAY UT
84117-5382
US

IV. Provider business mailing address

1200 5TH AVE STE 800
SEATTLE WA
98101-3136
US

V. Phone/Fax

Practice location:
  • Phone: 206-374-0109
  • Fax: 206-374-0108
Mailing address:
  • Phone: 206-374-0101
  • Fax: 206-374-0108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: ADRIENNE C BENNETT
Title or Position: CLINIC COORDINATOR
Credential: BS
Phone: 425-361-9272