Provider Demographics
NPI:1336438639
Name:UTAH COUNTY DIVISION OF SUBSTANCE ABUSE
Entity Type:Organization
Organization Name:UTAH COUNTY DIVISION OF SUBSTANCE ABUSE
Other - Org Name:FOOTHILL OUTPATIENT
Other - Org Type:Other Name
Authorized Official - Title/Position:PRIMARY THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BLU
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:LSAC, CPCI
Authorized Official - Phone:801-851-7114
Mailing Address - Street 1:151 S UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-4427
Mailing Address - Country:US
Mailing Address - Phone:801-851-7114
Mailing Address - Fax:
Practice Address - Street 1:151 S UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-4427
Practice Address - Country:US
Practice Address - Phone:801-851-7114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility