Healthcare Provider Details

I. General information

NPI: 1669155362
Provider Name (Legal Business Name): NAT-SU BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

491 S MAIN ST
TOOELE UT
84074-2747
US

IV. Provider business mailing address

491 S MAIN ST
TOOELE UT
84074-2747
US

V. Phone/Fax

Practice location:
  • Phone: 435-850-1823
  • Fax: 435-850-1911
Mailing address:
  • Phone: 435-850-1823
  • Fax: 435-850-1911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL BRENNAN
Title or Position: BILLING DIRECTOR
Credential:
Phone: 385-529-8735