Provider Demographics
NPI:1083732051
Name:ADOLESCENT, CHILD AND FAMILY THERAPY CLINIC, INC
Entity Type:Organization
Organization Name:ADOLESCENT, CHILD AND FAMILY THERAPY CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:B
Authorized Official - Last Name:OLDS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:801-652-4937
Mailing Address - Street 1:515 S 700 E
Mailing Address - Street 2:STE 3A
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2873
Mailing Address - Country:US
Mailing Address - Phone:801-652-4937
Mailing Address - Fax:
Practice Address - Street 1:370 E SOUTH TEMPLE
Practice Address - Street 2:STE 550
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1206
Practice Address - Country:US
Practice Address - Phone:801-652-4937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2152474405364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Single Specialty