Provider Demographics
NPI:1891898045
Name:CHRYSALIS UTAH, LLC
Entity Type:Organization
Organization Name:CHRYSALIS UTAH, LLC
Other - Org Name:CHRYSALIS
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MMHC
Authorized Official - Phone:801-655-4950
Mailing Address - Street 1:1443 W 800 N
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-2875
Mailing Address - Country:US
Mailing Address - Phone:801-655-4950
Mailing Address - Fax:801-655-4954
Practice Address - Street 1:1443 W 800 N
Practice Address - Street 2:SUITE 103
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-2875
Practice Address - Country:US
Practice Address - Phone:801-655-4950
Practice Address - Fax:801-655-4954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 103K00000X
UT320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT788007788140Medicaid