Provider Demographics
NPI:1285195446
Name:RED MESA HOUSING CASE MANAGEMENT
Entity Type:Organization
Organization Name:RED MESA HOUSING CASE MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACTING EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:S
Authorized Official - Last Name:FLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DMFT, LMFT
Authorized Official - Phone:801-214-7681
Mailing Address - Street 1:120 W 1300 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-5230
Mailing Address - Country:US
Mailing Address - Phone:801-214-7681
Mailing Address - Fax:801-214-7685
Practice Address - Street 1:580 S 500 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-2209
Practice Address - Country:US
Practice Address - Phone:801-746-6852
Practice Address - Fax:801-746-7687
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:URBAN INDIAN CENTER OF SALT LAKE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-28
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11544773158Medicaid