Provider Demographics
NPI:1275853855
Name:BLUE PEAK ACADMEY FOR YOUNG WOMEN
Entity Type:Organization
Organization Name:BLUE PEAK ACADMEY FOR YOUNG WOMEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELL
Authorized Official - Middle Name:B
Authorized Official - Last Name:SORENON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-638-7476
Mailing Address - Street 1:PO BOX 440369
Mailing Address - Street 2:
Mailing Address - City:KOOSHAREM
Mailing Address - State:UT
Mailing Address - Zip Code:84744-0369
Mailing Address - Country:US
Mailing Address - Phone:435-638-7476
Mailing Address - Fax:435-638-7476
Practice Address - Street 1:525 N 100 W
Practice Address - Street 2:
Practice Address - City:KOOSHAREM
Practice Address - State:UT
Practice Address - Zip Code:84744-0369
Practice Address - Country:US
Practice Address - Phone:435-638-7476
Practice Address - Fax:435-638-7476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-07
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT16303322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children