Provider Demographics
NPI:1356353692
Name:SAN JUAN MENTAL HEALTH-SUBSTANCE ABUSE SPECIAL SERVICE DISTRICT
Entity type:Organization
Organization Name:SAN JUAN MENTAL HEALTH-SUBSTANCE ABUSE SPECIAL SERVICE DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JED
Authorized Official - Middle Name:E
Authorized Official - Last Name:LYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LSCW
Authorized Official - Phone:435-678-2992
Mailing Address - Street 1:356 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLANDING
Mailing Address - State:UT
Mailing Address - Zip Code:84511-3830
Mailing Address - Country:US
Mailing Address - Phone:435-678-2992
Mailing Address - Fax:435-678-3116
Practice Address - Street 1:356 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLANDING
Practice Address - State:UT
Practice Address - Zip Code:84511-3830
Practice Address - Country:US
Practice Address - Phone:435-678-2992
Practice Address - Fax:435-678-3116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11054261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT876000305005Medicaid
UT876000305005Medicaid