Provider Demographics
NPI:1568510550
Name:FAMILY SUPPORT CENTER
Entity Type:Organization
Organization Name:FAMILY SUPPORT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:M
Authorized Official - Last Name:RICKS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-955-9110
Mailing Address - Street 1:1760 W 4805 S
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84118-1177
Mailing Address - Country:US
Mailing Address - Phone:801-955-9110
Mailing Address - Fax:801-955-9411
Practice Address - Street 1:777 W CENTER ST
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-7148
Practice Address - Country:US
Practice Address - Phone:801-955-9411
Practice Address - Fax:801-955-9411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT17474101YM0800X
UT12358251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty