Provider Demographics
NPI:1164669081
Name:INTERMOUNTAIN SPECIALIZED ABUSE TREATMENT CENTER (ISAT)
Entity Type:Organization
Organization Name:INTERMOUNTAIN SPECIALIZED ABUSE TREATMENT CENTER (ISAT)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:HAFEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-373-0210
Mailing Address - Street 1:1868 N 1120 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1179
Mailing Address - Country:US
Mailing Address - Phone:801-373-0210
Mailing Address - Fax:801-373-0215
Practice Address - Street 1:1868 N 1120 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1179
Practice Address - Country:US
Practice Address - Phone:801-373-0210
Practice Address - Fax:801-373-0215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT271649-3501251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health