Provider Demographics
NPI:1811306616
Name:CROSSROADS YOUTH SERVICES INC
Entity type:Organization
Organization Name:CROSSROADS YOUTH SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER/ CEO
Authorized Official - Prefix:
Authorized Official - First Name:CAREY
Authorized Official - Middle Name:TEUILA
Authorized Official - Last Name:OFAHENGAUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-602-4039
Mailing Address - Street 1:120 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-2146
Mailing Address - Country:US
Mailing Address - Phone:801-528-3247
Mailing Address - Fax:801-753-0409
Practice Address - Street 1:120 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-2146
Practice Address - Country:US
Practice Address - Phone:801-528-3247
Practice Address - Fax:801-753-0409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3762253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1770721300Medicaid