Provider Demographics
NPI:1740873355
Name:WISE MIND BEHAVIORAL THERAPY, PLLC
Entity type:Organization
Organization Name:WISE MIND BEHAVIORAL THERAPY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIVLOVITZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-477-7004
Mailing Address - Street 1:160 S 1000 E STE 330
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1454
Mailing Address - Country:US
Mailing Address - Phone:801-477-7004
Mailing Address - Fax:
Practice Address - Street 1:160 S 1000 E STE 330
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1454
Practice Address - Country:US
Practice Address - Phone:801-477-7004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-15
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty