Provider Demographics
NPI: | 1700168374 |
---|---|
Name: | EQUINE JOURNEYS, LLC |
Entity Type: | Organization |
Organization Name: | EQUINE JOURNEYS, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CLINICAL DIRECTOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | BRANDON |
Authorized Official - Middle Name: | M |
Authorized Official - Last Name: | BURR |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LCSW |
Authorized Official - Phone: | 435-836-2535 |
Mailing Address - Street 1: | PO BOX 69 |
Mailing Address - Street 2: | |
Mailing Address - City: | LOA |
Mailing Address - State: | UT |
Mailing Address - Zip Code: | 84747-0069 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 435-836-2535 |
Mailing Address - Fax: | 435-836-2537 |
Practice Address - Street 1: | 14 NORTH MAIN STREET |
Practice Address - Street 2: | |
Practice Address - City: | LOA |
Practice Address - State: | UT |
Practice Address - Zip Code: | 84747 |
Practice Address - Country: | US |
Practice Address - Phone: | 435-836-2535 |
Practice Address - Fax: | 435-836-2537 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2011-09-09 |
Last Update Date: | 2011-09-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
UT | 18393 | 322D00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 322D00000X | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |