Healthcare Provider Details

I. General information

NPI: 1023834173
Provider Name (Legal Business Name): ROSECREST MENTAL HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2024
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7984 S 1300 E
SANDY UT
84094-0744
US

IV. Provider business mailing address

7984 S 1300 E
SANDY UT
84094-0744
US

V. Phone/Fax

Practice location:
  • Phone: 801-906-1074
  • Fax:
Mailing address:
  • Phone: 801-906-1074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: IVY CHRISTIANSEN
Title or Position: OWNER/OPERATOR
Credential: LMFT
Phone: 801-906-1074