Provider Demographics
NPI:1033539895
Name:STARLIGHT PROGRAM
Entity Type:Organization
Organization Name:STARLIGHT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PERFETTO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-747-3556
Mailing Address - Street 1:345 E 4500 S
Mailing Address - Street 2:#260
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3991
Mailing Address - Country:US
Mailing Address - Phone:801-747-3556
Mailing Address - Fax:801-747-2086
Practice Address - Street 1:345 E 4500 S
Practice Address - Street 2:#260
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-3991
Practice Address - Country:US
Practice Address - Phone:801-747-3556
Practice Address - Fax:801-747-2086
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PERFETTO CLINICAL CONTRACTING INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4215253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1497071419Medicaid