Provider Demographics
NPI:1760839484
Name:PDY CORP
Entity Type:Organization
Organization Name:PDY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:DEYOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-755-0928
Mailing Address - Street 1:3232 S 1575 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-3355
Mailing Address - Country:US
Mailing Address - Phone:801-755-0928
Mailing Address - Fax:
Practice Address - Street 1:2319 S FOOTHILL DR STE 180
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-5403
Practice Address - Country:US
Practice Address - Phone:801-755-0928
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1025453501251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000078304OtherMEDICARE PTAN#