Provider Demographics
NPI:1477189900
Name:RED WILLOW IOP, PLLC
Entity Type:Organization
Organization Name:RED WILLOW IOP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-556-6007
Mailing Address - Street 1:1425 S 700 E STE 102
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2125
Mailing Address - Country:US
Mailing Address - Phone:385-313-0055
Mailing Address - Fax:
Practice Address - Street 1:1425 S 700 E STE 102
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-2125
Practice Address - Country:US
Practice Address - Phone:385-313-0055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RED WILLOW COUNSELING AND RECOVERY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder