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General NPI Number Information
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NPI Number | 1891398285
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Entity Type | Organization
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Legal Business Name | WISE MIND ONLINE THERAPY
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Dates
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Enumeration Date | 11/18/2020
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Last Update Date | 11/18/2020
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Provider Practice Location Address
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Address Line | 915 N 510 E
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City | OREM
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State | UT
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Zip | 84097-3374
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Country | US
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Telephone | 208-243-3332
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Fax |
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Provider Business Mailing Address
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Address Line | 915 N 510 E
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City | OREM
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State | UT
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Zip | 84097-3374
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Country | US
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Telephone | 208-243-3332
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Fax |
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Authorized Official
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Title or Position | OWNER / SHARE HOLDER
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Name | MR. TRAVIS REED STEPHENS
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Credential | LCSW
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Telephone | 208-243-3332
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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