=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306361399
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MISTALYN JOY DEMANN LAMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2017
-----------------------------------------------------
Last Update Date | 09/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4505 S WASATCH BLVD STE 290
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84124-4204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 385-695-5949
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9035 S 1300 E STE 120
-----------------------------------------------------
City | SANDY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84094-3192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 117513533904
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------