Provider Demographics
NPI:1336686856
Name:WASATCH PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:WASATCH PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:WILKES
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:540-421-6660
Mailing Address - Street 1:1443 E LAIRD AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-1938
Mailing Address - Country:US
Mailing Address - Phone:540-421-6660
Mailing Address - Fax:
Practice Address - Street 1:1060 E 100 S
Practice Address - Street 2:SUITE 100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1501
Practice Address - Country:US
Practice Address - Phone:801-590-0525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10086571-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty