Healthcare Provider Details

I. General information

NPI: 1255974085
Provider Name (Legal Business Name): UNIVERSAL HEALTH SYSTEMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2019
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 N UNIVERSITY AVE
PROVO UT
84604-5504
US

IV. Provider business mailing address

4501 N UNIVERSITY AVE
PROVO UT
84604-5504
US

V. Phone/Fax

Practice location:
  • Phone: 801-932-6364
  • Fax:
Mailing address:
  • Phone: 801-932-2532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MAX AH QUIN
Title or Position: CLINICAL DIRECTOR
Credential: CMHC
Phone: 801-932-2544