Provider Demographics
NPI:1356843114
Name:CHRYSALIS UTAH, INC.
Entity Type:Organization
Organization Name:CHRYSALIS UTAH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-655-4950
Mailing Address - Street 1:1443 W 800 N STE 103
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-2878
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1507 S 180 E
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-5570
Practice Address - Country:US
Practice Address - Phone:801-426-6661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHRYSALIS UTAH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty