Provider Demographics
NPI:1720389844
Name:UNIVERSITY OF UTAH
Entity Type:Organization
Organization Name:UNIVERSITY OF UTAH
Other - Org Name:ASSESSMENT & REFERRAL SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:ASSOCIATE PROFESSOR OF PSYCHIATRY
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PDD
Authorized Official - Phone:801-532-1850
Mailing Address - Street 1:450 S 900 E STE 300
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-3064
Mailing Address - Country:US
Mailing Address - Phone:801-534-7921
Mailing Address - Fax:
Practice Address - Street 1:450 S 900 E STE 300
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-3064
Practice Address - Country:US
Practice Address - Phone:801-534-7921
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6262094-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty