Provider Demographics
NPI:1063679785
Name:UTAH STATE UNIVERSITY
Entity Type:Organization
Organization Name:UTAH STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAMS ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHEGAY
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-797-1415
Mailing Address - Street 1:1415 OLD MAIN HILL
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84322-1415
Mailing Address - Country:US
Mailing Address - Phone:435-797-1226
Mailing Address - Fax:
Practice Address - Street 1:6813 OLD MAIN HILL
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84322-6813
Practice Address - Country:US
Practice Address - Phone:435-797-3822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health