Provider Demographics
NPI:1356357115
Name:WASATCH BEHAVIORAL HEALTH SPECIAL SERVICE DISTRICT
Entity type:Organization
Organization Name:WASATCH BEHAVIORAL HEALTH SPECIAL SERVICE DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DIRECTORE
Authorized Official - Prefix:MR
Authorized Official - First Name:DORAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-373-4760
Mailing Address - Street 1:750 N FREEDOM BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601
Mailing Address - Country:US
Mailing Address - Phone:801-373-4760
Mailing Address - Fax:801-373-0639
Practice Address - Street 1:750 N FREEDOM BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601
Practice Address - Country:US
Practice Address - Phone:801-373-4760
Practice Address - Fax:801-373-0639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 261QM0801X, 261QR0405X, 251S00000X
UT261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870285565012Medicaid
UT000057426Medicare ID - Type Unspecified