Provider Demographics
NPI:1225326044
Name:ST. GEORGE CHILDREN & FAMILY PSYCHIATRIC CENTER PC
Entity Type:Organization
Organization Name:ST. GEORGE CHILDREN & FAMILY PSYCHIATRIC CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CANTRIL
Authorized Official - Middle Name:
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-652-1897
Mailing Address - Street 1:230 N 1680 E STE H1
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-2584
Mailing Address - Country:US
Mailing Address - Phone:435-652-1897
Mailing Address - Fax:435-652-5909
Practice Address - Street 1:230 N 1680 E STE H1
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2584
Practice Address - Country:US
Practice Address - Phone:435-652-1897
Practice Address - Fax:435-652-5909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-13
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1494471205174400000X
UT68747874408364SP0810X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No364SP0810XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & FamilyGroup - Multi-Specialty