Provider Demographics
NPI:1235682345
Name:EAGLE RANCH OUTPATIENT SERVICES
Entity Type:Organization
Organization Name:EAGLE RANCH OUTPATIENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BAWDEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:435-922-0440
Mailing Address - Street 1:91 W 1470 S
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-6709
Mailing Address - Country:US
Mailing Address - Phone:435-922-0440
Mailing Address - Fax:
Practice Address - Street 1:91 W 1470 S
Practice Address - Street 2:SUITE 101
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-6709
Practice Address - Country:US
Practice Address - Phone:435-922-0440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAGLE RANCH ACADEMY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT53606263904101Y00000X, 106H00000X
UT53606266006101YA0400X
UT5360626 3904251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty