Healthcare Provider Details

I. General information

NPI: 1659192425
Provider Name (Legal Business Name): PINEBROOK MENTAL HEALTH THERAPY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 12/22/2024
Certification Date: 12/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 PINEBROOK RD STE 1250B
PARK CITY UT
84098-5663
US

IV. Provider business mailing address

3100 PINEBROOK RD STE 1250B
PARK CITY UT
84098-5663
US

V. Phone/Fax

Practice location:
  • Phone: 435-562-1903
  • Fax:
Mailing address:
  • Phone: 435-562-1903
  • 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: DR. JACQUELINE HYDE
Title or Position: CEO
Credential: PSYD, CMHC
Phone: 435-562-1903