Provider Demographics
NPI:1982958641
Name:INTERMOUNTAIN SENIOR CLINIC
Entity type:Organization
Organization Name:INTERMOUNTAIN SENIOR CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:KAY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:SIMONS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:801-314-4550
Mailing Address - Street 1:5770 S 250E SUITE 210
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107
Mailing Address - Country:US
Mailing Address - Phone:801-314-4544
Mailing Address - Fax:801-314-4565
Practice Address - Street 1:5770 S 250E SUITE 210
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:801-314-4544
Practice Address - Fax:801-314-4565
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTERMOUNTAIN HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-02
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6262134-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty