Healthcare Provider Details

I. General information

NPI: 1639828361
Provider Name (Legal Business Name): INNSAEI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

264 W CENTER ST
OREM UT
84057-4637
US

IV. Provider business mailing address

264 W CENTER ST
OREM UT
84057-4637
US

V. Phone/Fax

Practice location:
  • Phone: 801-225-4027
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KRISTIN TUDSANDOS
Title or Position: BUSINESS MANAGER
Credential:
Phone: 385-221-0200