MEDICARE: UNI BEHAVIORAL HEALTH CLINICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1720140114
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNI BEHAVIORAL HEALTH CLINICS

Provider Business Mailing Address
First Line	:	PO BOX 413076
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84141-3076
Country	:	US
Telephone Number	:	801-585-1212
Fax Number	:	801-585-9096

Provider Business Practice Location Address
First Line	:	650 KOMAS DR
Second Line	:	208
City	:	SLC
State	:	UT
Zip	:	84108-1215
Country	:	US
Telephone Number	:	801-585-1212
Fax Number	:	801-585-9096

Authorized Official
Title or Position	:	CONTRACTING DIRECTOR
Name	:	JEANNINE RUSHTON-FOWLER
Credential	:
Telephone Number	:	801-587-6336

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	05/28/2015

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Practice Location Address:

650 KOMAS DR , 206
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84108-1215

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1649459488 — JEANNE GARFIELD MSW
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1689941049 — REBECCA GLOVER SSW
Practice Location Address:

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84108-1215

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1588931950 — CHARISSE LYN SAGERS
Practice Location Address:

650 KOMAS DR , 200
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84108-1215

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1720355100 — MELISSA ANN BREWER RN
Practice Location Address:

650 KOMAS DR , 200
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84108-1215

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1477820843 — MARK JEFFERSON LANCE
Practice Location Address:

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