Healthcare Provider Details

I. General information

NPI: 1831979988
Provider Name (Legal Business Name): INTIMATE RELATIONSHIPS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2023
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 E 770 N
OREM UT
84097-4101
US

IV. Provider business mailing address

520 E 770 N
OREM UT
84097-4101
US

V. Phone/Fax

Practice location:
  • Phone: 801-850-7063
  • Fax:
Mailing address:
  • Phone: 801-850-7063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY RUSSELL
Title or Position: OWNER
Credential: LMFT
Phone: 801-850-7063