Provider Demographics
NPI:1164586061
Name:J MANUEL DE LA TORRE INC
Entity Type:Organization
Organization Name:J MANUEL DE LA TORRE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:DE LA TORRE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-973-0655
Mailing Address - Street 1:1579 W 6005
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84104-2512
Mailing Address - Country:US
Mailing Address - Phone:801-973-0655
Mailing Address - Fax:801-973-0655
Practice Address - Street 1:1579 W 6005
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84104-2512
Practice Address - Country:US
Practice Address - Phone:801-973-0655
Practice Address - Fax:801-973-0655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13150735011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT518647999000Medicaid
UT518647999013Medicaid
UT518647999000Medicaid