Provider Demographics
NPI:1023318300
Name:SUNDANCE CANYON ACADEMY
Entity type:Organization
Organization Name:SUNDANCE CANYON ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:REYNIE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:SANDOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-735-6407
Mailing Address - Street 1:6948 DUSTY ROSE DR
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-4710
Mailing Address - Country:US
Mailing Address - Phone:801-446-6206
Mailing Address - Fax:801-446-6978
Practice Address - Street 1:6948 DUSTY ROSE DR
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-4710
Practice Address - Country:US
Practice Address - Phone:801-446-6206
Practice Address - Fax:801-446-6978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT17166320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness