Healthcare Provider Details

I. General information

NPI: 1184377285
Provider Name (Legal Business Name): INTEGRATIVE AMD HOLISTIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 N MAIN ST STE 202
KAYSVILLE UT
84037-1278
US

IV. Provider business mailing address

375 N MAIN ST STE 202
KAYSVILLE UT
84037-1278
US

V. Phone/Fax

Practice location:
  • Phone: 801-923-3290
  • Fax:
Mailing address:
  • Phone: 801-923-3290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SOPHIE ARCHIBALD
Title or Position: OWNER/THERAPIST
Credential: LCSW
Phone: 801-923-3290