Basic Information
| Provider Information | |||||||||
| NPI: | 1639582521 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UINTAH BASIN TRICOUNTY MENTAL HEALTH & SUBSTANCE ABUSE LOCAL AUTHORITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHEASTERN COUNSELING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1140 W 500 S STE 9 | ||||||||
| Address2: | |||||||||
| City: | VERNAL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840782912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357256300 | ||||||||
| FaxNumber: | 4357256325 | ||||||||
| Practice Location | |||||||||
| Address1: | 285 W 800 S | ||||||||
| Address2: | |||||||||
| City: | ROOSEVELT | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840663707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357256300 | ||||||||
| FaxNumber: | 4357256325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2014 | ||||||||
| LastUpdateDate: | 06/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | SNOW | ||||||||
| AuthorizedOfficialFirstName: | KYLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4357256300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
No ID Information.