Healthcare Provider Details

I. General information

NPI: 1780884742
Provider Name (Legal Business Name): LIFELINE BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 04/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 W CENTER ST
NORTH SALT LAKE UT
84054-2917
US

IV. Provider business mailing address

1130 W CENTER ST
NORTH SALT LAKE UT
84054-2917
US

V. Phone/Fax

Practice location:
  • Phone: 801-936-4000
  • Fax:
Mailing address:
  • Phone: 801-936-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. SHANE R PETERSEN
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MBA
Phone: 801-936-4000