Healthcare Provider Details

I. General information

NPI: 1649380593
Provider Name (Legal Business Name): KIDS BEHAVIORAL HEALTH OF UTAH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 03/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5899 RIVENDELL DR
WEST JORDAN UT
84088-5700
US

IV. Provider business mailing address

5899 RIVENDELL DR
WEST JORDAN UT
84088-5700
US

V. Phone/Fax

Practice location:
  • Phone: 801-561-3377
  • Fax: 801-569-3274
Mailing address:
  • Phone: 801-561-3377
  • Fax: 801-569-3274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number11944
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number11944
License Number StateUT

VIII. Authorized Official

Name: STEVE FILTON
Title or Position: SRVPCFO
Credential:
Phone: 610-738-3300