Healthcare Provider Details

I. General information

NPI: 1588847008
Provider Name (Legal Business Name): INTERMOUNTAIN MENTAL HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5012 S TIMBER WAY UNIT 206
MILLCREEK UT
84117-5875
US

IV. Provider business mailing address

PO BOX 57885
MURRAY UT
84157-0885
US

V. Phone/Fax

Practice location:
  • Phone: 801-673-4841
  • Fax:
Mailing address:
  • Phone: 801-673-4841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2774677-2501
License Number StateUT

VIII. Authorized Official

Name: DR. MORRIS N. LEWIS JR.
Title or Position: PRESIDENT
Credential: PHD
Phone: 801-673-4841