Healthcare Provider Details

I. General information

NPI: 1437985694
Provider Name (Legal Business Name): CULTIVATE WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 W 200 S STE 107
MOAB UT
84532-2534
US

IV. Provider business mailing address

PO BOX 729
NORWOOD CO
81423-0729
US

V. Phone/Fax

Practice location:
  • Phone: 970-708-8190
  • Fax:
Mailing address:
  • Phone: 970-708-8190
  • 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: MESA OWEN
Title or Position: OWNER
Credential: LCSW
Phone: 970-708-8190