Healthcare Provider Details

I. General information

NPI: 1891398285
Provider Name (Legal Business Name): WISE MIND ONLINE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N 510 E
OREM UT
84097-3374
US

IV. Provider business mailing address

915 N 510 E
OREM UT
84097-3374
US

V. Phone/Fax

Practice location:
  • Phone: 208-243-3332
  • Fax:
Mailing address:
  • Phone: 208-243-3332
  • 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: MR. TRAVIS REED STEPHENS
Title or Position: OWNER / SHARE HOLDER
Credential: LCSW
Phone: 208-243-3332