Provider Demographics
NPI:1891036497
Name:THETA MANAGEMENT CORPORATION
Entity type:Organization
Organization Name:THETA MANAGEMENT CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERNAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-852-1400
Mailing Address - Street 1:524 W 300 N
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-2667
Mailing Address - Country:US
Mailing Address - Phone:801-852-1400
Mailing Address - Fax:
Practice Address - Street 1:524 W 300 N
Practice Address - Street 2:SUITE 102
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-2667
Practice Address - Country:US
Practice Address - Phone:801-852-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT101YA0400X, 101YM0800X, 103T00000X, 103TA0400X, 1041C0700X, 111N00000X, 133NN1002X, 163WA0400X, 163WC0400X, 164W00000X, 171M00000X, 174H00000X, 175L00000X, 246RP1900X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)Group - Multi-Specialty
No163WC0400XNursing Service ProvidersRegistered NurseCase ManagementGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No175L00000XOther Service ProvidersHomeopathGroup - Multi-Specialty
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Multi-Specialty