Healthcare Provider Details

I. General information

NPI: 1174852289
Provider Name (Legal Business Name): INTERMOUNTAIN PSYCHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2009
Last Update Date: 03/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3544 LINCOLN AVE SUITE C
OGDEN UT
84401-4045
US

IV. Provider business mailing address

PO BOX 17586
SALT LAKE CITY UT
84117-0586
US

V. Phone/Fax

Practice location:
  • Phone: 801-913-0098
  • Fax: 801-272-3857
Mailing address:
  • Phone: 801-913-0098
  • Fax: 801-272-3857

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: DR. RANDY LYNN RYAN
Title or Position: REGISTERED AGENT
Credential: PSY.D.
Phone: 801-913-0098