MEDICARE: INTERMOUNTAIN CENTER FOR COGNITIVE THERAPY

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	12368	UT

General Provider Information

NPI Number	:	1821129859
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERMOUNTAIN CENTER FOR COGNITIVE THERAPY

Provider Business Mailing Address
First Line	:	111 E 5600 S
Second Line	:	SUITE 318
City	:	MURRAY
State	:	UT
Zip	:	84107-6174
Country	:	US
Telephone Number	:	801-268-2887
Fax Number	:	801-268-4295

Provider Business Practice Location Address
First Line	:	111 E 5600 S
Second Line	:	SUITE 318
City	:	MURRAY
State	:	UT
Zip	:	84107-6174
Country	:	US
Telephone Number	:	801-268-2887
Fax Number	:	801-268-4295

Authorized Official
Title or Position	:	CEO
Name	:	DR. DONNA CASTLETON
Credential	:	LCSW
Telephone Number	:	801-268-2887

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	08/22/2020

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