MEDICARE: A CHILD'S PLACE, 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	103TC2200X	Clinical Child & Adolescent Psychologist

General Provider Information

NPI Number	:	1851233282
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A CHILD'S PLACE, LLC

Provider Business Mailing Address
First Line	:	4568 S HIGHLAND DR STE 100
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4234
Country	:	US
Telephone Number	:	801-232-5363
Fax Number	:

Provider Business Practice Location Address
First Line	:	4568 S HIGHLAND DR STE 100
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4234
Country	:	US
Telephone Number	:	801-232-5363
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PSYCHOLOIGST
Name	:	CARLA JEAN REYES
Credential	:	PH.D.
Telephone Number	:	801-232-5363

Provider Enumeration Date	:	04/06/2026
Last Update Date	:	04/06/2026

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