MEDICARE: INTEGRATED PSYCHOTHERAPY SERVICES

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	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760037675
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED PSYCHOTHERAPY SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 508
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84110-0508
Country	:	US
Telephone Number	:	801-520-7938
Fax Number	:	800-528-1208

Provider Business Practice Location Address
First Line	:	352 S DENVER ST STE 315
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-3054
Country	:	US
Telephone Number	:	801-520-7938
Fax Number	:	800-528-1208

Authorized Official
Title or Position	:	CLINICIAN
Name	:	JOSEPH R. GOUVEIA-GRANT
Credential	:	CMHC
Telephone Number	:	801-520-7938

Provider Enumeration Date	:	08/07/2019
Last Update Date	:	07/20/2021

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Directions to “INTEGRATED PSYCHOTHERAPY SERVICES ” Practice Location

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