Provider Demographics
NPI:1073811196
Name:CHRYSALIS TEXAS
Entity Type:Organization
Organization Name:CHRYSALIS TEXAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-360-4672
Mailing Address - Street 1:531 E 770 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-4102
Mailing Address - Country:US
Mailing Address - Phone:801-655-4950
Mailing Address - Fax:801-655-4954
Practice Address - Street 1:531 E 770 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-4102
Practice Address - Country:US
Practice Address - Phone:801-655-4950
Practice Address - Fax:801-655-4954
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHRYSALIS UTAH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-14
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities