Provider Demographics
NPI:1356744791
Name:SUMMIT CLINICAL SERVICES OF UTAH LLC
Entity type:Organization
Organization Name:SUMMIT CLINICAL SERVICES OF UTAH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:HAKES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-414-3252
Mailing Address - Street 1:1561 W 7000 S STE 200
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-3556
Mailing Address - Country:US
Mailing Address - Phone:801-263-0717
Mailing Address - Fax:801-266-2362
Practice Address - Street 1:1561 W 7000 S STE 200
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-3556
Practice Address - Country:US
Practice Address - Phone:801-263-0717
Practice Address - Fax:801-266-2362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-30
Last Update Date:2021-02-26
Deactivation Date:2020-06-17
Deactivation Code:
Reactivation Date:2021-02-26
Provider Licenses
StateLicense IDTaxonomies
UT364873-4405363LP0808X
UT5244527-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty