Provider Demographics
NPI:1629619010
Name:UTAH STATE UNIVERSITY
Entity Type:Organization
Organization Name:UTAH STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMENTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-797-5830
Mailing Address - Street 1:6405 OLD MAIN HILL
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84322-0001
Mailing Address - Country:US
Mailing Address - Phone:435-797-0576
Mailing Address - Fax:844-308-5865
Practice Address - Street 1:6405 OLD MAIN HILL
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84322-0001
Practice Address - Country:US
Practice Address - Phone:435-797-0576
Practice Address - Fax:844-308-5865
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UTAH STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1447715701Medicaid