Provider Demographics
NPI:1669691499
Name:LDS FAMILY SERVICES
Entity type:Organization
Organization Name:LDS FAMILY SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AGENCY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GILLIES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-422-7620
Mailing Address - Street 1:1190 N 900 E
Mailing Address - Street 2:204
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3536
Mailing Address - Country:US
Mailing Address - Phone:801-422-7620
Mailing Address - Fax:801-422-0165
Practice Address - Street 1:1190 N 900 E
Practice Address - Street 2:204
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3536
Practice Address - Country:US
Practice Address - Phone:801-422-7620
Practice Address - Fax:801-422-0165
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LDS FAMILY SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-24
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12208261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)