Basic Information
Provider Information | |||||||||
NPI: | 1477819878 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MT PLEASANT CAMPUS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 747 E SAINT GEORGE BLVD | ||||||||
Address2: |   | ||||||||
City: | SAINT GEORGE | ||||||||
State: | UT | ||||||||
PostalCode: | 847703035 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4356736111 | ||||||||
FaxNumber: | 4356730994 | ||||||||
Practice Location | |||||||||
Address1: | 1170 SOUTH 70 WEST | ||||||||
Address2: |   | ||||||||
City: | MT. PLEASANT | ||||||||
State: | UT | ||||||||
PostalCode: | 84647 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8018994111 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/10/2012 | ||||||||
LastUpdateDate: | 06/24/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PACE | ||||||||
AuthorizedOfficialFirstName: | BRIAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 4356736111 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MA ED, MC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3245S0500X | 18409 | UT | N |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children | 323P00000X | 18409 | UT | N |   | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |   | 322D00000X | 18409 | UT | Y |   | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |   |
No ID Information.