Provider Demographics
NPI:1255706636
Name:UNIVERSITY OF UTAH BEHAVIORAL HEALTH SELF PAY CLINIC
Entity type:Organization
Organization Name:UNIVERSITY OF UTAH BEHAVIORAL HEALTH SELF PAY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE CHAIR, CLINICAL AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-587-6336
Mailing Address - Street 1:PO BOX 413076
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84141-3076
Mailing Address - Country:US
Mailing Address - Phone:801-213-3900
Mailing Address - Fax:
Practice Address - Street 1:650 S KOMAS DR
Practice Address - Street 2:206
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1215
Practice Address - Country:US
Practice Address - Phone:801-585-1212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty