Provider Demographics
NPI:1780884742
Name:LIFELINE BEHAVIORAL HEALTH, LLC
Entity type:Organization
Organization Name:LIFELINE BEHAVIORAL HEALTH, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:801-936-4000
Mailing Address - Street 1:1130 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-2917
Mailing Address - Country:US
Mailing Address - Phone:801-936-4000
Mailing Address - Fax:
Practice Address - Street 1:1130 W CENTER ST
Practice Address - Street 2:
Practice Address - City:NORTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84054-2917
Practice Address - Country:US
Practice Address - Phone:801-936-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder