| Great Salt Lake Wellness Inc. | |
|
375 N Main St Ste 202 Kaysville UT 84037-1278 | |
| (801) 844-1615 | |
| (801) 825-1162 |
| Full Name | Great Salt Lake Wellness Inc. |
|---|---|
| Speciality | Psychologist |
| Location | 375 N Main St Ste 202, Kaysville, Utah |
| Authorized Official Name and Position | Emily Young Bullock (OWNER) |
| Authorized Official Contact | 8018883236 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Great Salt Lake Wellness Inc. 375 N Main St Ste 202 Kaysville UT 84037-1278 Ph: (801) 844-1615 | Great Salt Lake Wellness Inc. 375 N Main St Ste 202 Kaysville UT 84037-1278 Ph: (801) 844-1615 |
| NPI Number | 1790152940 |
|---|---|
| Provider Enumeration Date | 08/24/2015 |
| Last Update Date | 10/27/2021 |
| Certification Date | 10/27/2021 |
| Medicare PECOS PAC ID | 4789985680 |
|---|---|
| Medicare Enrollment ID | O20151218000873 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1790152940 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | 7510289-2501 (Utah) | Primary |
| Provider Name | Emily Y Bullock |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1760670962 PECOS PAC ID: 3375777840 Enrollment ID: I20131016001404 |
| Provider Name | Jill Lynn Perry |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1073939807 PECOS PAC ID: 2769738863 Enrollment ID: I20180703001201 |
| Provider Name | Jeanne Marine Foster |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1922760594 PECOS PAC ID: 1254717861 Enrollment ID: I20221005002952 |
| Provider Name | Paige Davis |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1629662143 PECOS PAC ID: 8921474966 Enrollment ID: I20221017002661 |
| Provider Name | Angela Wignall Schultz |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1306425152 PECOS PAC ID: 4284080508 Enrollment ID: I20231023003309 |
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