Healthcare Provider Details

I. General information

NPI: 1407955883
Provider Name (Legal Business Name): WASATCH YOUTH SUPPORT SYSTEMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 08/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3392 W 3500 S
WEST VALLEY CITY UT
84119-2630
US

IV. Provider business mailing address

3392 WEST 3500 SOUTH
WEST VALLEY CITY UT
84119-2630
US

V. Phone/Fax

Practice location:
  • Phone: 801-969-3307
  • Fax:
Mailing address:
  • Phone: 801-969-3307
  • Fax: 801-964-8898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number5420921-3501
License Number State

VIII. Authorized Official

Name: DR. JAMES RUSSELL MARCHEL
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D
Phone: 801-969-3307