Provider Demographics
NPI:1265632939
Name:BLUE SAGE YOUTH SERVICES
Entity Type:Organization
Organization Name:BLUE SAGE YOUTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:C
Authorized Official - Last Name:HUSBANDS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:435-835-4053
Mailing Address - Street 1:PO BOX 6
Mailing Address - Street 2:
Mailing Address - City:MANTI
Mailing Address - State:UT
Mailing Address - Zip Code:84642-0006
Mailing Address - Country:US
Mailing Address - Phone:435-835-4053
Mailing Address - Fax:
Practice Address - Street 1:580 WEST 1500 SOUTH
Practice Address - Street 2:
Practice Address - City:MANTI
Practice Address - State:UT
Practice Address - Zip Code:84648
Practice Address - Country:US
Practice Address - Phone:435-835-4053
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12439322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children