Provider Demographics
NPI:1790088011
Name:WASATCH YOUTH SUPPORT SYSTEMS
Entity Type:Organization
Organization Name:WASATCH YOUTH SUPPORT SYSTEMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENCEY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:MARCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:801-969-3307
Mailing Address - Street 1:3392 W 3500 S
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-2630
Mailing Address - Country:US
Mailing Address - Phone:801-969-3307
Mailing Address - Fax:801-964-8988
Practice Address - Street 1:3392 W 3500 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-2630
Practice Address - Country:US
Practice Address - Phone:801-969-3307
Practice Address - Fax:801-964-8988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT293074-3501261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT261QR0405XMedicaid