Provider Demographics
NPI:1053821728
Name:ABS UT PC
Entity Type:Organization
Organization Name:ABS UT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:WIGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-900-0681
Mailing Address - Street 1:16255 VENTURA BLVD STE 900
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2317
Mailing Address - Country:US
Mailing Address - Phone:801-935-4171
Mailing Address - Fax:801-935-4946
Practice Address - Street 1:240 MORRIS AVE STE 100
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-3278
Practice Address - Country:US
Practice Address - Phone:801-935-4171
Practice Address - Fax:801-935-4946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-06
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty