Provider Demographics
NPI:1184033656
Name:CHRYSALIS UTAH, LLC
Entity Type:Organization
Organization Name:CHRYSALIS UTAH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:YARGER
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:801-404-6023
Mailing Address - Street 1:1443 W 800 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-2875
Mailing Address - Country:US
Mailing Address - Phone:801-404-6023
Mailing Address - Fax:
Practice Address - Street 1:1443 W 800 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-2875
Practice Address - Country:US
Practice Address - Phone:801-404-6023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-08
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTAO1532320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities