Provider Demographics
NPI:1790898526
Name:SAN JUAN MENTAL HEALTH-SUBSTANCE ABUSE SSD
Entity Type:Organization
Organization Name:SAN JUAN MENTAL HEALTH-SUBSTANCE ABUSE SSD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:435-678-2992
Mailing Address - Street 1:356 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLANDING
Mailing Address - State:UT
Mailing Address - Zip Code:84511-3830
Mailing Address - Country:US
Mailing Address - Phone:435-678-2992
Mailing Address - Fax:435-678-3116
Practice Address - Street 1:356 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLANDING
Practice Address - State:UT
Practice Address - Zip Code:84511-3830
Practice Address - Country:US
Practice Address - Phone:435-678-2992
Practice Address - Fax:435-678-3116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11054261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT876000546138Medicaid
UT0055506Medicare ID - Type Unspecified