Organization
LIFE INTEGRATIVE HEALTH CENTER
Active
Other names
Theta Wellness Center - Provo
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. KENDRA BERNAL MA (CLINICAL ADMINISTRATOR)
(801) 869-8199
Entity
Organization
Contact information
Practice address
777 N 500 W, SUITE 104, PROVO, UT 84601-1541
(801) 869-8199
(801) 705-0436
Mailing address
777 N 500 W STE 104, PROVO, UT 84601-1541
(801) 869-8199
(801) 705-0436
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
—
—
261QH0100X
Health Service Clinic/Center
0000000
UT
261QH0100X
Health Service Clinic/Center
NOT REQUIRED
UT
261QM0850X
Adult Mental Health Clinic/Center
00000000000
UT
261QM0850X
Adult Mental Health Clinic/Center
NOT REQUIRED
UT
261QM0855X
Adolescent and Children Mental Health Clinic/Center
NOT REQUIRED
UT
Other
Enumeration date
12/26/2013
Last updated
04/09/2014
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