Provider Demographics
NPI:1689139198
Name:MMTC
Entity Type:Organization
Organization Name:MMTC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:CHENGAPPA
Authorized Official - Suffix:
Authorized Official - Credentials:SSW
Authorized Official - Phone:801-425-2679
Mailing Address - Street 1:1411 W 1100 N
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-1634
Mailing Address - Country:US
Mailing Address - Phone:801-425-2679
Mailing Address - Fax:
Practice Address - Street 1:1411 W 1100 N
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-1634
Practice Address - Country:US
Practice Address - Phone:801-425-2679
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1093173510Medicaid