Healthcare Provider Details

I. General information

NPI: 1326745787
Provider Name (Legal Business Name): RIVENDELL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2023
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3507 N UNIVERSITY AVE STE 350F
PROVO UT
84604-4478
US

IV. Provider business mailing address

3507 N UNIVERSITY AVE STE 350F
PROVO UT
84604-4478
US

V. Phone/Fax

Practice location:
  • Phone: 385-446-5010
  • Fax: 385-446-5012
Mailing address:
  • Phone: 385-446-5010
  • Fax: 385-446-5012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SARAH INGERSON
Title or Position: DR
Credential: DNP
Phone: 385-985-8423