Provider Demographics
NPI:1659192425
Name:PINEBROOK MENTAL HEALTH THERAPY INC.
Entity type:Organization
Organization Name:PINEBROOK MENTAL HEALTH THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HYDE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, CMHC
Authorized Official - Phone:435-562-1903
Mailing Address - Street 1:3100 PINEBROOK RD STE 1250B
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-5663
Mailing Address - Country:US
Mailing Address - Phone:435-562-1903
Mailing Address - Fax:
Practice Address - Street 1:3100 PINEBROOK RD STE 1250B
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-5663
Practice Address - Country:US
Practice Address - Phone:435-562-1903
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-23
Last Update Date:2024-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty