Provider Demographics
NPI:1053671123
Name:CROSSROADS ACADEMY
Entity Type:Organization
Organization Name:CROSSROADS ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:DAHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PHD, LMFT
Authorized Official - Phone:801-334-5051
Mailing Address - Street 1:914 32ND ST
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-0718
Mailing Address - Country:US
Mailing Address - Phone:801-334-5051
Mailing Address - Fax:801-760-4638
Practice Address - Street 1:914 32ND ST
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-0718
Practice Address - Country:US
Practice Address - Phone:801-334-5051
Practice Address - Fax:801-760-4638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility