Provider Demographics
NPI:1093729048
Name:NUTCRACKER
Entity Type:Organization
Organization Name:NUTCRACKER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL ADVISER
Authorized Official - Prefix:
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:
Authorized Official - Last Name:WASHBURN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-423-3267
Mailing Address - Street 1:PO BOX 786
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:UT
Mailing Address - Zip Code:84653-0786
Mailing Address - Country:US
Mailing Address - Phone:801-423-3267
Mailing Address - Fax:801-423-3276
Practice Address - Street 1:251 WEST HWY 198
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:UT
Practice Address - Zip Code:84653-0786
Practice Address - Country:US
Practice Address - Phone:801-423-3267
Practice Address - Fax:801-423-3276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14605112052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty