Healthcare Provider Details

I. General information

NPI: 1639895790
Provider Name (Legal Business Name): CENTER FOR TRAUMA, RECOVERY, AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2022
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 E 11190 S
SANDY UT
84094-5329
US

IV. Provider business mailing address

929 E 11190 S
SANDY UT
84094-5329
US

V. Phone/Fax

Practice location:
  • Phone: 801-215-9334
  • Fax:
Mailing address:
  • Phone: 801-215-9334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN MEAGHAN FRY
Title or Position: OWNER
Credential: PH.D.
Phone: 978-815-4800