Healthcare Provider Details

I. General information

NPI: 1033407606
Provider Name (Legal Business Name): REDWOOD THERAPY AND YOUTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 W MAIN ST
AMERICAN FORK UT
84003-2359
US

IV. Provider business mailing address

154 W MAIN ST
AMERICAN FORK UT
84003-2359
US

V. Phone/Fax

Practice location:
  • Phone: 801-885-1216
  • Fax:
Mailing address:
  • Phone: 801-885-1216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number18025
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number18028
License Number StateUT

VIII. Authorized Official

Name: MR. ADNEY MA'ANAIMA MARION REID
Title or Position: CLINICAL DIRECTOR
Credential: LCSW
Phone: 801-885-1216