Provider Demographics
NPI:1639822042
Name:MODERN FAMILY THERAPY SERVICES LIMITED LIABILITY COMPANY
Entity Type:Organization
Organization Name:MODERN FAMILY THERAPY SERVICES LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-896-3284
Mailing Address - Street 1:5040 S 3300 W
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-8666
Mailing Address - Country:US
Mailing Address - Phone:801-896-3284
Mailing Address - Fax:
Practice Address - Street 1:4933 S 1500 W STE 200
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:UT
Practice Address - Zip Code:84405-7738
Practice Address - Country:US
Practice Address - Phone:801-896-3284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty