Provider Demographics
NPI:1083611966
Name:WESTERN NEUROLOGICAL ASSOCIATES INC
Entity Type:Organization
Organization Name:WESTERN NEUROLOGICAL ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-262-3441
Mailing Address - Street 1:1151 E 3900 S
Mailing Address - Street 2:#B150
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1216
Mailing Address - Country:US
Mailing Address - Phone:801-262-3441
Mailing Address - Fax:801-269-9005
Practice Address - Street 1:1151 E 3900 S
Practice Address - Street 2:#B150
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1216
Practice Address - Country:US
Practice Address - Phone:801-262-3441
Practice Address - Fax:801-269-9005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
UT2084N0400X, 2084N0402X
UT00559262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870446965007Medicaid
UT00055926OtherMEDICARE PTAN
UT870446965007Medicaid