Provider Demographics
NPI: | 1558876961 |
---|---|
Name: | CORNER CANYON RECOVERY, LLC |
Entity Type: | Organization |
Organization Name: | CORNER CANYON RECOVERY, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | EXECUTIVE DIRECTOR |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | BRADLEY |
Authorized Official - Middle Name: | RANDALL |
Authorized Official - Last Name: | CHRISTENSEN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 801-994-1849 |
Mailing Address - Street 1: | 1450 E PIONEER RD |
Mailing Address - Street 2: | |
Mailing Address - City: | DRAPER |
Mailing Address - State: | UT |
Mailing Address - Zip Code: | 84020-9618 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 801-994-1849 |
Mailing Address - Fax: | 801-384-0820 |
Practice Address - Street 1: | 1450 E PIONEER RD |
Practice Address - Street 2: | |
Practice Address - City: | DRAPER |
Practice Address - State: | UT |
Practice Address - Zip Code: | 84020 |
Practice Address - Country: | US |
Practice Address - Phone: | 801-994-1849 |
Practice Address - Fax: | 801-384-0820 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-12-07 |
Last Update Date: | 2020-05-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
UT | 51329 | 101YA0400X, 101YM0800X, 103TA0400X, 103TC1900X, 1041C0700X, 106H00000X, 2084A0401X, 2084P0800X, 2084P0802X, 225800000X, 225C00000X, 261Q00000X, 261QM0850X, 324500000X, 363A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 324500000X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Group - Multi-Specialty | |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
No | 103TA0400X | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
No | 103TC1900X | Behavioral Health & Social Service Providers | Psychologist | Counseling | Group - Multi-Specialty |
No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Multi-Specialty | |
No | 2084A0401X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | Group - Multi-Specialty |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
No | 2084P0802X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | Group - Multi-Specialty |
No | 225800000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Recreation Therapist | Group - Multi-Specialty | |
No | 225C00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Counselor | Group - Multi-Specialty | |
No | 261Q00000X | Ambulatory Health Care Facilities | Clinic/Center | Group - Multi-Specialty | |
No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | Group - Multi-Specialty |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty |