Healthcare Provider Details

I. General information

NPI: 1083485650
Provider Name (Legal Business Name): WHITE BISON THERAPY COLLECTIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2024
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11075 S STATE ST STE 2
SANDY UT
84070-5151
US

IV. Provider business mailing address

11075 S STATE ST STE 2
SANDY UT
84070-5151
US

V. Phone/Fax

Practice location:
  • Phone: 970-556-3798
  • Fax:
Mailing address:
  • Phone: 970-556-3798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. LORI LUND
Title or Position: OWNER
Credential: LMFT
Phone: 970-556-3798