Provider Demographics
NPI:1356373807
Name:UTAH STATE UNIVERSITY, CENTER FOR PERSONS WITH DISABILITIES
Entity type:Organization
Organization Name:UTAH STATE UNIVERSITY, CENTER FOR PERSONS WITH DISABILITIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIVISION DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-797-7461
Mailing Address - Street 1:6810 OLD MAIN HL
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84322-0001
Mailing Address - Country:US
Mailing Address - Phone:435-797-7461
Mailing Address - Fax:
Practice Address - Street 1:6810 OLD MAIN HL
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84322-0001
Practice Address - Country:US
Practice Address - Phone:435-797-7461
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT876000545680Medicaid