Healthcare Provider Details

I. General information

NPI: 1730251844
Provider Name (Legal Business Name): DYBREAK BEHAVIORAL HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 WEST 200 SOUTH
FARMINGTON UT
84025-1036
US

IV. Provider business mailing address

PO BOX 1036 117 WEST 200 SOUTH
FARMINGTON UT
84025-1036
US

V. Phone/Fax

Practice location:
  • Phone: 801-451-4843
  • Fax: 801-451-2839
Mailing address:
  • Phone: 801-451-4843
  • Fax: 801-451-2839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. STAN FILLMORE
Title or Position: BUSINESS ADMINISTRATOR
Credential: LCSW
Phone: 801-451-4843