Healthcare Provider Details

I. General information

NPI: 1417345760
Provider Name (Legal Business Name): SUNDANCE BEHAVIORAL RESOURCES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2015
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 E 4800 S STE 200
MURRAY UT
84107-5041
US

IV. Provider business mailing address

845 E 4800 S STE 200
MURRAY UT
84107-5041
US

V. Phone/Fax

Practice location:
  • Phone: 801-264-9522
  • Fax: 801-265-9604
Mailing address:
  • Phone: 801-264-9522
  • Fax: 801-265-9604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number251B00000X
License Number StateUT

VIII. Authorized Official

Name: ELISABETH PESCE
Title or Position: CEO
Credential:
Phone: 904-605-4986