Provider Demographics
NPI:1770054348
Name:THERAPEUTIC LIFESTYLE CENTER OF UTAH
Entity type:Organization
Organization Name:THERAPEUTIC LIFESTYLE CENTER OF UTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIHM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-691-7064
Mailing Address - Street 1:1151 E 3900 S STE B175
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1255
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1151 E 3900 S STE B175
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1255
Practice Address - Country:US
Practice Address - Phone:801-691-7064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty