GREAT SALT LAKE WELLNESS INC – Clinical Psychologist, NPI 1790152940
Clinical Psychologist
Main info
Profile Insights
NPPES metrics only — not quality of care.
Provider Addresses for GREAT SALT LAKE WELLNESS INC
375 N MAIN ST STE 202
KAYSVILLE, UT 840371278
Phone: (801) 844-1615
Fax: (385) 209-2975
Type: Mailing
PO BOX 95970
SOUTH JORDAN, UT 840950970
Phone: (801) 352-9500
Fax: (801) 352-9502
Type: Mailing
1477 N 2000 W
SUITE E
CLINTON, UT 840158638
Phone: (801) 614-5866
Fax: (801) 825-1162
Type: Location
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
No Open Payments data available for this provider.
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Medicare Enrollment & Revalidation
Source: CMS public data · Not endorsed by CMS ·
Educational use only—not medical, billing, or legal advice.
PECOS enrollment status
Participating (accepts Medicare assignment)
Enrollment effective: 2015-12-18
PECOS data refreshed: 2026-05-27
Medicare revalidation (CMS due date list)
Past revalidation due date
Earliest CMS due date was 2025-10-31 (226 days ago).
Enrollment records
1
Earliest due date
2025-10-31
CMS data updated
2026-06-01
Revalidation progress
- Medicare enrolled
- On CMS revalidation list
- Due date assigned
- Revalidate in PECOS
CMS enrollment records
| Enrollment ID | Type | Specialty | State | Due date |
|---|---|---|---|---|
| O20151218000873 | O | Clinic/Group Practice | UT | 2025-10-31 |
What to do next
- Verify current status on the CMS Revalidation Lookup Tool immediately.
- Complete revalidation in PECOS or contact your Medicare Administrative Contractor (MAC).
- Overdue revalidation can lead to deactivation of Medicare billing privileges.
Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS
Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
Educational use only—not medical, billing, or legal advice.
No Medicare fee-for-service utilization data available for this provider in our database.
Insurance plans in this area (ZIP 84037)
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