Healthcare Provider Details

I. General information

NPI: 1558895094
Provider Name (Legal Business Name): UNIVERSITY OF UTAH PEDIATRIC BEHAVIORAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 N MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1125
US

IV. Provider business mailing address

PO BOX 841450
LOS ANGELES CA
90084-1450
US

V. Phone/Fax

Practice location:
  • Phone: 801-587-2255
  • Fax:
Mailing address:
  • Phone: 801-213-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JON KAR ZUBIETA
Title or Position: DEPARTMENT CHAIR
Credential: MD
Phone: 801-587-6336