Provider Demographics
NPI:1275787251
Name:WINDGATE WILDERNESS THERAPY, LLC
Entity Type:Organization
Organization Name:WINDGATE WILDERNESS THERAPY, LLC
Other - Org Name:WINGATE WILDERNESS THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MAJORITY PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:DUPELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-585-1862
Mailing Address - Street 1:PO BOX 347
Mailing Address - Street 2:
Mailing Address - City:KANAB
Mailing Address - State:UT
Mailing Address - Zip Code:84741-0347
Mailing Address - Country:US
Mailing Address - Phone:435-817-1574
Mailing Address - Fax:435-304-3199
Practice Address - Street 1:1739 S HIGHWAY 89A
Practice Address - Street 2:BUILDING A
Practice Address - City:KANAB
Practice Address - State:UT
Practice Address - Zip Code:84741-3957
Practice Address - Country:US
Practice Address - Phone:435-817-1574
Practice Address - Fax:435-304-3199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14113322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children