Provider Demographics
NPI:1477175560
Name:AUTHENTICITY UTAH PLLC
Entity Type:Organization
Organization Name:AUTHENTICITY UTAH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:CONDER
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:435-720-8338
Mailing Address - Street 1:2265 S STATE ST APT 272
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-1405
Mailing Address - Country:US
Mailing Address - Phone:435-720-8338
Mailing Address - Fax:
Practice Address - Street 1:2265 S STATE ST APT 272
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-1405
Practice Address - Country:US
Practice Address - Phone:435-720-8338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)