Provider Demographics
NPI:1720590060
Name:SILVER CREEK PSYCHIATRY
Entity Type:Organization
Organization Name:SILVER CREEK PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GLEAVE
Authorized Official - Suffix:
Authorized Official - Credentials:RN/DON
Authorized Official - Phone:801-830-8541
Mailing Address - Street 1:1478 E 820 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-5481
Mailing Address - Country:US
Mailing Address - Phone:801-830-8541
Mailing Address - Fax:
Practice Address - Street 1:1478 E 820 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-5481
Practice Address - Country:US
Practice Address - Phone:801-830-8541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-26
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2017-31336261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT822587494OtherMEDICAL