Basic Information
| Provider Information | |||||||||
| NPI: | 1891235701 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SEQUEL YOUTH SERVICES OF FALCON RIDGE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FALCON RIDGE RANCH | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 790099 | ||||||||
| Address2: | |||||||||
| City: | VIRGIN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847790099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356355260 | ||||||||
| FaxNumber: | 4356355327 | ||||||||
| Practice Location | |||||||||
| Address1: | 747 E SAINT GEORGE BLVD | ||||||||
| Address2: | FALCON RIDGE RANCH | ||||||||
| City: | SAINT GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847703035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356355260 | ||||||||
| FaxNumber: | 4356355327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2017 | ||||||||
| LastUpdateDate: | 02/27/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 4356355260 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CARE YOUTH CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MHC, CMHC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | 84001266004 | UT | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
No ID Information.