Provider Demographics
NPI:1912125337
Name:SALT LAKE COUNTY FOR ITS YOUTH SERVICES DIVISION
Entity Type:Organization
Organization Name:SALT LAKE COUNTY FOR ITS YOUTH SERVICES DIVISION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIVISION DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:385-468-4501
Mailing Address - Street 1:2001 SOUTH STATE STREET
Mailing Address - Street 2:SUITE N4100
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84190-1021
Mailing Address - Country:US
Mailing Address - Phone:801-468-2332
Mailing Address - Fax:801-468-3712
Practice Address - Street 1:177 WEST PRICE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-4345
Practice Address - Country:US
Practice Address - Phone:801-269-7500
Practice Address - Fax:801-269-7550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT47632166004101YA0400X
UT1169286004101YA0400X
UT3470473502101YA0400X
UT56931903502101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTHT0004001Medicaid
UTHT002258OtherUTAH HEALTH