Provider Demographics
NPI:1851152847
Name:CREATIVE MINDS UT
Entity Type:Organization
Organization Name:CREATIVE MINDS UT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAZZAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:LIFE COACH
Authorized Official - Phone:702-945-1065
Mailing Address - Street 1:411 W 7200 S STE 411W7200
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-1058
Mailing Address - Country:US
Mailing Address - Phone:702-945-1065
Mailing Address - Fax:
Practice Address - Street 1:411 W 7200 S STE 411W7200
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-1058
Practice Address - Country:US
Practice Address - Phone:702-945-1065
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health