Healthcare Provider Details

I. General information

NPI: 1790630325
Provider Name (Legal Business Name): INSTITUTE FOR SELF-DETERMINED RELATIONSHIPS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2026
Last Update Date: 02/27/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1452 E 820 N UPPR LEVEL
OREM UT
84097-5481
US

IV. Provider business mailing address

1452 E 820 N UPPR LEVEL
OREM UT
84097-5481
US

V. Phone/Fax

Practice location:
  • Phone: 801-648-9664
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. BRADY C EISERT
Title or Position: OWNER
Credential: LMFT
Phone: 801-648-9664