Provider Demographics
NPI:1790152940
Name:GREAT SALT LAKE WELLNESS INC
Entity Type:Organization
Organization Name:GREAT SALT LAKE WELLNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:YOUNG
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:801-389-9521
Mailing Address - Street 1:375 N MAIN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-1278
Mailing Address - Country:US
Mailing Address - Phone:801-844-1615
Mailing Address - Fax:385-209-2975
Practice Address - Street 1:375 N MAIN ST STE 202
Practice Address - Street 2:
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-1278
Practice Address - Country:US
Practice Address - Phone:801-844-1615
Practice Address - Fax:801-825-1162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-24
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7510289-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty