Provider Demographics
NPI:1407464886
Name:WASATCH FRONT TRAIL VENTURE
Entity Type:Organization
Organization Name:WASATCH FRONT TRAIL VENTURE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MORGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:435-513-2715
Mailing Address - Street 1:61 E 1600 N
Mailing Address - Street 2:
Mailing Address - City:GENOLA
Mailing Address - State:UT
Mailing Address - Zip Code:84655-5090
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:61 E 1600 N
Practice Address - Street 2:
Practice Address - City:GENOLA
Practice Address - State:UT
Practice Address - Zip Code:84655-5090
Practice Address - Country:US
Practice Address - Phone:435-513-2715
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty