Basic Information
Provider Information | |||||||||
NPI: | 1548348873 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UINTAH BASIN TRI-COUNTY MENTAL HEALTH AND SUBSTANCE ABUSE LOCAL AUTHOR | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NORTHEASTERN COUNSELING CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1908 | ||||||||
Address2: |   | ||||||||
City: | VERNAL | ||||||||
State: | UT | ||||||||
PostalCode: | 840785908 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4357256300 | ||||||||
FaxNumber: | 4357256325 | ||||||||
Practice Location | |||||||||
Address1: | 1140 W 500 S | ||||||||
Address2: |   | ||||||||
City: | VERNAL | ||||||||
State: | UT | ||||||||
PostalCode: | 840782914 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4357256300 | ||||||||
FaxNumber: | 4357256325 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2006 | ||||||||
LastUpdateDate: | 08/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SNOW | ||||||||
AuthorizedOfficialFirstName: | KYLE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 4357256300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.