Provider Demographics
NPI:1407169907
Name:MIND, BODY, SOUL, UTAH
Entity Type:Organization
Organization Name:MIND, BODY, SOUL, UTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:NUTTALL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-906-8780
Mailing Address - Street 1:699 E SOUTH TEMPLE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1142
Mailing Address - Country:US
Mailing Address - Phone:801-906-8780
Mailing Address - Fax:
Practice Address - Street 1:699 E SOUTH TEMPLE
Practice Address - Street 2:SUITE 300
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1142
Practice Address - Country:US
Practice Address - Phone:801-906-8780
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-26
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)