Healthcare Provider Details

I. General information

NPI: 1033811401
Provider Name (Legal Business Name): MILLCREEK THERAPY PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1398 E LUCK LN
MILLCREEK UT
84106-2944
US

IV. Provider business mailing address

1398 E LUCK LN
MILLCREEK UT
84106-2944
US

V. Phone/Fax

Practice location:
  • Phone: 801-870-3716
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: NANCY KIMMERLY
Title or Position: OWNER / LCSW
Credential: LCSW
Phone: 801-870-3716