Provider Demographics
NPI:1386194751
Name:EAGLE RANCH ACADEMY
Entity Type:Organization
Organization Name:EAGLE RANCH ACADEMY
Other - Org Name:EAGLE RANCH OUTPATIENT SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL 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:435-652-8488
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:435-652-8488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT53606263904106H00000X
UT5360626 3904251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty