Provider Demographics
NPI:1003045667
Name:SEGO LILY CENTER FOR THE ABUSED DEAF
Entity Type:Organization
Organization Name:SEGO LILY CENTER FOR THE ABUSED DEAF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOENE
Authorized Official - Middle Name:FARRIS
Authorized Official - Last Name:NICOLAISEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:888-328-5486
Mailing Address - Street 1:PO BOX 71279
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171-0279
Mailing Address - Country:US
Mailing Address - Phone:888-328-5486
Mailing Address - Fax:888-328-5486
Practice Address - Street 1:6526 S STATE ST
Practice Address - Street 2:404
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7261
Practice Address - Country:US
Practice Address - Phone:888-328-5486
Practice Address - Fax:888-328-5486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-03
Last Update Date:2009-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT50526596004251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT251S00000XMedicaid