1184790370 NPI number — BEHAVIORAL HEALTH ASSOCIATES OF UTAH LLC

Table of content: (NPI 1184790370)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184790370 NPI number — BEHAVIORAL HEALTH ASSOCIATES OF UTAH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEHAVIORAL HEALTH ASSOCIATES OF UTAH LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184790370
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
108 N MAIN ST
Provider Second Line Business Mailing Address:
SUITE I
Provider Business Mailing Address City Name:
RICHFIELD
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84701-2168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-896-5165
Provider Business Mailing Address Fax Number:
435-578-8008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
108 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE I
Provider Business Practice Location Address City Name:
RICHFIELD
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84701-2168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-896-5165
Provider Business Practice Location Address Fax Number:
435-578-8008
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FRANCE
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PSYCHOLOGIST
Authorized Official Telephone Number:
801-580-9192

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  368809-6004 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103T00000X , with the licence number: 1022722501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 148271300 . This is a "DEPT OF LABOR OWCP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 24703 . This is a "PEHP PREFERRED PROVIDER" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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