Provider Demographics
NPI:1760037675
Name:INTEGRATED PSYCHOTHERAPY SERVICES
Entity Type:Organization
Organization Name:INTEGRATED PSYCHOTHERAPY SERVICES
Other - Org Name:IPSSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:GOUVEIA-GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:CMHC
Authorized Official - Phone:801-520-7938
Mailing Address - Street 1:PO BOX 508
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-0508
Mailing Address - Country:US
Mailing Address - Phone:801-520-7938
Mailing Address - Fax:800-528-1208
Practice Address - Street 1:352 S DENVER ST STE 315
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-3054
Practice Address - Country:US
Practice Address - Phone:801-520-7938
Practice Address - Fax:800-528-1208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-07
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1790125730Medicaid