Provider Demographics
NPI: | 1144594003 |
---|---|
Name: | I PROMISE FOUNDATION |
Entity Type: | Organization |
Organization Name: | I PROMISE FOUNDATION |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | EXECUTIVE DIRECTOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | KENDRA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BERNAL |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 801-472-9780 |
Mailing Address - Street 1: | 223 W BULLDOG BLVD # 443 |
Mailing Address - Street 2: | |
Mailing Address - City: | PROVO |
Mailing Address - State: | UT |
Mailing Address - Zip Code: | 84604-2546 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 801-472-9780 |
Mailing Address - Fax: | 801-426-4615 |
Practice Address - Street 1: | 3521 N UNIVERSITY AVE |
Practice Address - Street 2: | SUITE 225 |
Practice Address - City: | PROVO |
Practice Address - State: | UT |
Practice Address - Zip Code: | 84604-4418 |
Practice Address - Country: | US |
Practice Address - Phone: | 801-472-9780 |
Practice Address - Fax: | 801-426-4615 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2012-02-23 |
Last Update Date: | 2012-02-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
UT | 19034 | 101YA0400X, 101YM0800X, 101YP1600X, 101YP2500X, 101YS0200X, 102L00000X, 103TA0400X, 103TB0200X, 103TC1900X, 103TP0016X, 103TP2701X, 1041C0700X, 106H00000X, 261QM0801X, 261QM0850X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Single Specialty |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Single Specialty |
No | 101YP1600X | Behavioral Health & Social Service Providers | Counselor | Pastoral | Group - Single Specialty |
No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Single Specialty |
No | 101YS0200X | Behavioral Health & Social Service Providers | Counselor | School | Group - Single Specialty |
No | 102L00000X | Behavioral Health & Social Service Providers | Psychoanalyst | Group - Single Specialty | |
No | 103TA0400X | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | Group - Single Specialty |
No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | Group - Single Specialty |
No | 103TC1900X | Behavioral Health & Social Service Providers | Psychologist | Counseling | Group - Single Specialty |
No | 103TP0016X | Behavioral Health & Social Service Providers | Psychologist | Prescribing (Medical) | Group - Single Specialty |
No | 103TP2701X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | Group - Single Specialty |
No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Single Specialty |
No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Single Specialty | |
No | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | Group - Single Specialty |
No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
UT | 19034 | Other | STATE OF UTAH - HEALTH & HUMAN SERVICES LICENSE |