Provider Demographics
NPI:1619412046
Name:AWAKENING BEHAVIORAL HEALTH, LLC
Entity Type:Organization
Organization Name:AWAKENING BEHAVIORAL HEALTH, LLC
Other - Org Name:RENAISSANCE RANCH TREATMENT CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CCO, EXEC DIR PAYOR RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KERRYLYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:BACA-PELPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-658-9646
Mailing Address - Street 1:2973 W 13800 S
Mailing Address - Street 2:
Mailing Address - City:BLUFFDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84065-8202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2973 W 13800 S
Practice Address - Street 2:
Practice Address - City:BLUFFDALE
Practice Address - State:UT
Practice Address - Zip Code:84065-8202
Practice Address - Country:US
Practice Address - Phone:801-545-0406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AWAKENING BEHAVIORAL HEALTH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-20
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
323P00000X
UT26066324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
1568909117OtherNPI FOR SPECIFIC FACILITY RENAISSANCE RANCH BLUFFDALE MEN'S PROGRAM, LLC
UT51983OtherSTATE OF UTAH HUMAN SERVICES