Provider Demographics
NPI:1891398285
Name:WISE MIND ONLINE THERAPY
Entity Type:Organization
Organization Name:WISE MIND ONLINE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / SHARE HOLDER
Authorized Official - Prefix:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:REED
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-243-3332
Mailing Address - Street 1:915 N 510 E
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-3374
Mailing Address - Country:US
Mailing Address - Phone:208-243-3332
Mailing Address - Fax:
Practice Address - Street 1:915 N 510 E
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-3374
Practice Address - Country:US
Practice Address - Phone:208-243-3332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty