Provider Demographics
NPI:1558432849
Name:EVOLUTION ACADEMY OF UTAH LLC
Entity Type:Organization
Organization Name:EVOLUTION ACADEMY OF UTAH LLC
Other - Org Name:COTTONWOOD TREATMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-433-2900
Mailing Address - Street 1:1144 W 3300 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-7175
Mailing Address - Country:US
Mailing Address - Phone:801-433-2900
Mailing Address - Fax:801-433-2999
Practice Address - Street 1:1144 W 3300 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-7175
Practice Address - Country:US
Practice Address - Phone:801-433-2900
Practice Address - Fax:801-433-2999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11353323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5168120Medicaid
MT4103783Medicaid
AKHS339PIMedicaid
WV3810005990Medicaid
VA4766Medicaid
NM55880347Medicaid
AKHS339PIMedicaid