Provider Demographics
NPI:1629561139
Name:PARADISE CREEK RECOVERY CENTER INC
Entity Type:Organization
Organization Name:PARADISE CREEK RECOVERY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:HEDELIUS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LCSW
Authorized Official - Phone:435-881-2500
Mailing Address - Street 1:40 W CACHE VALLEY BLVD STE 10A
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-8450
Mailing Address - Country:US
Mailing Address - Phone:435-787-2272
Mailing Address - Fax:435-713-4001
Practice Address - Street 1:2666 S HIGHWAY 81
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:ID
Practice Address - Zip Code:83342-8749
Practice Address - Country:US
Practice Address - Phone:855-442-1912
Practice Address - Fax:435-713-4001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty