Provider Demographics
NPI:1912234865
Name:RANDY RAY ENTERPRISES LLC
Entity Type:Organization
Organization Name:RANDY RAY ENTERPRISES LLC
Other - Org Name:INTENTIONAL FAMILY INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER/PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:801-738-4369
Mailing Address - Street 1:2936 LAKE MARY DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-5331
Mailing Address - Country:US
Mailing Address - Phone:801-860-9627
Mailing Address - Fax:
Practice Address - Street 1:3900 SOUTH AVENUE, 220 EAST AVENUE
Practice Address - Street 2:SUITE 7
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:801-738-4369
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-13
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT59432763902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11798095OtherCAQH