Provider Demographics
NPI:1902865595
Name:CHILD&FAMILY INSTITUTE FOR ASSESSMENT AND PSYCHOTHERAPY, LLC
Entity Type:Organization
Organization Name:CHILD&FAMILY INSTITUTE FOR ASSESSMENT AND PSYCHOTHERAPY, LLC
Other - Org Name:CHILD & FAMILY INSTITUTE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PEDIATRIC NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:SANTOSUSSO
Authorized Official - Last Name:GALE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:435-645-9240
Mailing Address - Street 1:1910 PROSPECTOR AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84060-7211
Mailing Address - Country:US
Mailing Address - Phone:435-645-9240
Mailing Address - Fax:435-645-9237
Practice Address - Street 1:1910 PROSPECTOR AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7211
Practice Address - Country:US
Practice Address - Phone:435-645-9240
Practice Address - Fax:435-645-9237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT377761-2501103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT149727806001Medicaid