Provider Demographics
NPI:1609404813
Name:UTAH LAKES NEUROSCIENCE MENTAL HEALTH CENTER PLLC
Entity Type:Organization
Organization Name:UTAH LAKES NEUROSCIENCE MENTAL HEALTH CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LILIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:RONEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:385-265-2484
Mailing Address - Street 1:223 W COUGAR BLVD # 704
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2546
Mailing Address - Country:US
Mailing Address - Phone:385-265-2484
Mailing Address - Fax:877-894-5104
Practice Address - Street 1:3549 N UNIVERSITY AVE STE 200
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-4417
Practice Address - Country:US
Practice Address - Phone:385-265-2484
Practice Address - Fax:877-894-5104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-01
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11486773-3501OtherLCSW LICENSE