Healthcare Provider Details

I. General information

NPI: 1033539895
Provider Name (Legal Business Name): STARLIGHT PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 04/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 E 4500 S #260
MURRAY UT
84107-3991
US

IV. Provider business mailing address

345 E 4500 S #260
MURRAY UT
84107-3991
US

V. Phone/Fax

Practice location:
  • Phone: 801-747-3556
  • Fax: 801-747-2086
Mailing address:
  • Phone: 801-747-3556
  • Fax: 801-747-2086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number4215
License Number StateUT

VIII. Authorized Official

Name: WILLIAM JOSEPH PERFETTO
Title or Position: DIRECTOR
Credential: LCSW
Phone: 801-747-3556