Provider Demographics
NPI:1013442052
Name:RECREATE THERAPY, PLLC
Entity type:Organization
Organization Name:RECREATE THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MARRIAGE AND FAMILY THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:AVA
Authorized Official - Middle Name:MARIE CRUMP
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LMFT
Authorized Official - Phone:435-632-7894
Mailing Address - Street 1:275 W 1750 S
Mailing Address - Street 2:APT #1
Mailing Address - City:PERRY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-4903
Mailing Address - Country:US
Mailing Address - Phone:435-494-1214
Mailing Address - Fax:
Practice Address - Street 1:2535 S HIGHWAY 89
Practice Address - Street 2:STE 4
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-6729
Practice Address - Country:US
Practice Address - Phone:435-494-1214
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9066126-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty