Healthcare Provider Details

I. General information

NPI: 1356744791
Provider Name (Legal Business Name): SUMMIT CLINICAL SERVICES OF UTAH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2014
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date: 06/17/2020
Reactivation Date: 02/26/2021

III. Provider practice location address

1561 W 7000 S STE 200
WEST JORDAN UT
84084-3556
US

IV. Provider business mailing address

1561 W 7000 S STE 200
WEST JORDAN UT
84084-3556
US

V. Phone/Fax

Practice location:
  • Phone: 801-263-0717
  • Fax: 801-266-2362
Mailing address:
  • Phone: 801-263-0717
  • Fax: 801-266-2362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5244527-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number364873-4405
License Number StateUT

VIII. Authorized Official

Name: MR. CHRIS C HAKES
Title or Position: OWNER
Credential: LCSW
Phone: 801-414-3252