Organization
INTERMOUNTAIN PSYCHOLOGY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. RANDY LYNN RYAN PSY.D. (REGISTERED AGENT)
(801) 913-0098
Entity
Organization
Contact information
Practice address
3544 LINCOLN AVE, SUITE C, OGDEN, UT 84401-4045
(801) 913-0098
(801) 272-3857
Mailing address
PO BOX 17586, SALT LAKE CITY, UT 84117-0586
(801) 913-0098
(801) 272-3857
Taxonomy
Speciality
Code
Description
License number
State
261QM0850X
Adult Mental Health Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000068518
MEDICARE PTAN
UT
Enumeration date
12/18/2009
Last updated
03/16/2010
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