Provider Demographics
NPI:1013070028
Name:CEREBRAL PALSY OF UTAH
Entity Type:Organization
Organization Name:CEREBRAL PALSY OF UTAH
Other - Org Name:FOUNDATIONS FOR INDEPENDENCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-266-1805
Mailing Address - Street 1:3550 S 700 W
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-4120
Mailing Address - Country:US
Mailing Address - Phone:801-266-1805
Mailing Address - Fax:801-266-2404
Practice Address - Street 1:3550 S 700 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-4120
Practice Address - Country:US
Practice Address - Phone:801-266-1805
Practice Address - Fax:801-266-2404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT320700000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities