Provider Demographics
NPI:1780019323
Name:UTAH CENTER FOR EVIDENCE BASED TREATMENT
Entity Type:Organization
Organization Name:UTAH CENTER FOR EVIDENCE BASED TREATMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:ELENA
Authorized Official - Last Name:LANGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:301-437-1381
Mailing Address - Street 1:164 S 900 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-4103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:164 S 900 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-4103
Practice Address - Country:US
Practice Address - Phone:301-437-1381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-13
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTLIC201303289251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health