Healthcare Provider Details

I. General information

NPI: 1144594003
Provider Name (Legal Business Name): I PROMISE FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2012
Last Update Date: 02/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3521 N UNIVERSITY AVE SUITE 225
PROVO UT
84604-4418
US

IV. Provider business mailing address

223 W BULLDOG BLVD # 443
PROVO UT
84604-2546
US

V. Phone/Fax

Practice location:
  • Phone: 801-472-9780
  • Fax: 801-426-4615
Mailing address:
  • Phone: 801-472-9780
  • Fax: 801-426-4615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number19034
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number19034
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number19034
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number19034
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number19034
License Number StateUT
# 6
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number19034
License Number StateUT
# 7
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number19034
License Number StateUT
# 8
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number19034
License Number StateUT
# 9
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number19034
License Number StateUT
# 10
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number19034
License Number StateUT
# 11
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number19034
License Number StateUT
# 12
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number19034
License Number StateUT
# 13
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number19034
License Number StateUT
# 14
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number19034
License Number StateUT
# 15
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number19034
License Number StateUT

VIII. Authorized Official

Name: KENDRA BERNAL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 801-472-9780