NPIMap

Organization Active NPI

Great Salt Lake Wellness Inc

  • Clinical Psychologist
  • Kaysville, UT
National Provider Identifier
1790152940
Registry record updated Apr 17, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
License
7510289-2501 Issued in UT
Legal business name
GREAT SALT LAKE WELLNESS INC
Practice address
375 N Main St Ste 202
Kaysville, UT 84037-1278
Phone
(801) 844-1615
Fax
(801) 825-1162
NPI assigned
Aug 24, 2015
Last updated
Apr 17, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 17, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Emily Young Bullock, PSYDNPI 1760670962
Title
Owner
Phone
(801) 389-9521

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Psychologist 103TC0700X 7510289-2501 UT Primary

Addresses

Primary practice location

375 N Main St Ste 202
Kaysville, UT 84037-1278

Mailing address

375 N Main St Ste 202
Kaysville, UT 84037-1278
Phone (801) 844-1615

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in UT

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20151218000873 UT Part B Supplier - Clinic/Group Practice 4789985680 Receives reassigned benefits from 6 practitioners
Practice locations: Kaysville, UT; Provo, UT; St George, UT; Woods Cross, UT

National Provider Directory

National Provider Directory

Locations

375 N Main St
Ste 202
Kaysville, UT 84037
Phone (385) 231-1500

75 S 200 E
Ste 100
Provo, UT 84606
Phone (801) 844-1615

1596 S 500 W
Ste 101
Woods Cross, UT 84010
Phone (801) 844-1615

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1440374400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1713312000000",
    "number": "1790152940",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "375 N MAIN ST STE 202",
            "city": "KAYSVILLE",
            "state": "UT",
            "postal_code": "840371278",
            "telephone_number": "801-844-1615",
            "fax_number": "385-209-2975"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "375 N MAIN ST STE 202",
            "city": "KAYSVILLE",
            "state": "UT",
            "postal_code": "840371278",
            "telephone_number": "801-844-1615",
            "fax_number": "801-825-1162"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT SALT LAKE WELLNESS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-08-24",
        "last_updated": "2024-04-17",
        "certification_date": "2024-04-17",
        "status": "A",
        "authorized_official_last_name": "BULLOCK",
        "authorized_official_first_name": "EMILY",
        "authorized_official_middle_name": "YOUNG",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "801-389-9521",
        "authorized_official_credential": "PSYD"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "UT",
            "license": "7510289-2501",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Kaysville, UT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 17, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.