=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225401763
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UTE TRIBE ALCOHOL/SUBSTANCE ABUSE PREVENTION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2015
-----------------------------------------------------
Last Update Date | 11/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 SOUTH 6777 EAST
-----------------------------------------------------
City | FORT DUCHESNE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-722-3234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 550 SOUTH 6777 EAST P.O.BOX 369
-----------------------------------------------------
City | FORT DUCHESNE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-722-3234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM DIRECTOR
-----------------------------------------------------
Name | ANTHONY GUZMAN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 435-722-3234
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------