Healthcare Provider Details

I. General information

NPI: 1144204926
Provider Name (Legal Business Name): BEHAVIORAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 07/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 W GORDON AVE
LAYTON UT
84041-6508
US

IV. Provider business mailing address

1767 N 2525 E
LAYTON UT
84040
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-7177
  • Fax: 801-498-7562
Mailing address:
  • Phone: 801-773-7177
  • Fax: 801-498-7562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: THOMAS FAIRBANK
Title or Position: PRES/OWNER
Credential: PH.D.
Phone: 801-773-7177