Provider Demographics
NPI:1811058076
Name:UTAH STATE UNIVERSITY
Entity type:Organization
Organization Name:UTAH STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:RECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-797-2032
Mailing Address - Street 1:2810 OLD MAIN HL
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84322-2810
Mailing Address - Country:US
Mailing Address - Phone:435-797-3401
Mailing Address - Fax:435-797-1448
Practice Address - Street 1:2810 OLD MAIN HL
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84322-2810
Practice Address - Country:US
Practice Address - Phone:435-797-3401
Practice Address - Fax:435-797-1448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5805022-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5805022250001OtherBLUE CROSS BLUE SHIELD
UT5805022250001OtherBLUE CROSS BLUE SHIELD