Healthcare Provider Details

I. General information

NPI: 1558259218
Provider Name (Legal Business Name): LIFE RENEWAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2025
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 W CENTER ST STE N104
PLEASANT GROVE UT
84062-3360
US

IV. Provider business mailing address

146 N 765 E
PLEASANT GROVE UT
84062-2879
US

V. Phone/Fax

Practice location:
  • Phone: 801-436-6747
  • Fax:
Mailing address:
  • Phone: 801-319-2041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAVID THOMPSON
Title or Position: OWNER/CLINICAL DIRECTOR
Credential: LMFT
Phone: 801-319-2041