Provider Demographics
NPI:1982011649
Name:TEEN DISCOVERY HOME
Entity Type:Organization
Organization Name:TEEN DISCOVERY HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:M
Authorized Official - Last Name:DIAMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-749-0966
Mailing Address - Street 1:PO BOX 101
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:UT
Mailing Address - Zip Code:84634-0101
Mailing Address - Country:US
Mailing Address - Phone:435-528-7400
Mailing Address - Fax:
Practice Address - Street 1:10 EAST 100 SOUTH
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:UT
Practice Address - Zip Code:84634
Practice Address - Country:US
Practice Address - Phone:435-528-7400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8293322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children