Provider Demographics
NPI:1558430389
Name:GRACE FORSYTHE PHD INC
Entity Type:Organization
Organization Name:GRACE FORSYTHE PHD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:A
Authorized Official - Last Name:FORSYTHE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, APRN
Authorized Official - Phone:801-273-7769
Mailing Address - Street 1:4271 NEPTUNE DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3362
Mailing Address - Country:US
Mailing Address - Phone:801-273-7769
Mailing Address - Fax:801-273-4073
Practice Address - Street 1:2046 MURRAY HOLLADAY RD
Practice Address - Street 2:103
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-5125
Practice Address - Country:US
Practice Address - Phone:801-273-7769
Practice Address - Fax:801-273-4073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2010-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2189134405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT267698Medicare UPIN
UT000012113Medicare ID - Type UnspecifiedPRIMARY LOCATION
UT000012112Medicare ID - Type UnspecifiedSECONDARY LOCATION