Healthcare Provider Details

I. General information

NPI: 1770294720
Provider Name (Legal Business Name): FULLY INTEGRATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2022
Last Update Date: 12/12/2022
Certification Date: 12/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

756 E 500 S
SALT LAKE CITY UT
84102-2906
US

IV. Provider business mailing address

756 E 500 S
SALT LAKE CITY UT
84102-2906
US

V. Phone/Fax

Practice location:
  • Phone: 435-590-0116
  • Fax:
Mailing address:
  • Phone: 435-590-0116
  • 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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JACOB STUCKI
Title or Position: CEO
Credential: LCSW
Phone: 435-590-0116