MEDICARE: INTEGRUM PSYCHOTHERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1114242724	OTHER		NPI
2	1518211705	OTHER		NPI

General Provider Information

NPI Number	:	1619455714
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRUM PSYCHOTHERAPY, LLC

Provider Business Mailing Address
First Line	:	1584 E GLEN ARBOR ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-3813
Country	:	US
Telephone Number	:	919-949-0486
Fax Number	:

Provider Business Practice Location Address
First Line	:	1174 E GRAYSTONE WAY STE 6
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2671
Country	:	US
Telephone Number	:	801-683-5330
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RYAN WALTER MORGAN
Credential	:	LCSW
Telephone Number	:	202-487-5244

Provider Enumeration Date	:	07/31/2018
Last Update Date	:	07/31/2018

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