Healthcare Provider Details

I. General information

NPI: 1891898045
Provider Name (Legal Business Name): CHRYSALIS UTAH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/21/2022
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1443 W 800 N SUITE 103
OREM UT
84057-2875
US

IV. Provider business mailing address

1443 W 800 N SUITE 103
OREM UT
84057-2875
US

V. Phone/Fax

Practice location:
  • Phone: 801-655-4950
  • Fax: 801-655-4954
Mailing address:
  • Phone: 801-655-4950
  • Fax: 801-655-4954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateUT

VIII. Authorized Official

Name: MARC ROBERT CHRISTENSEN
Title or Position: CHIEF OPERATIONS OFFICER
Credential: MMHC
Phone: 801-655-4950