Provider Demographics
NPI:1497525125
Name:SYCAMORE MENTAL HEALTH
Entity Type:Organization
Organization Name:SYCAMORE MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:RASMUSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-588-9538
Mailing Address - Street 1:669 S APPALOOSA CIR
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:UT
Mailing Address - Zip Code:84340-9629
Mailing Address - Country:US
Mailing Address - Phone:801-588-9538
Mailing Address - Fax:
Practice Address - Street 1:111 E FOREST ST STE H
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-2127
Practice Address - Country:US
Practice Address - Phone:801-588-9538
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1982106852Medicaid