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General NPI Number Information
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NPI Number | 1932467495
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Entity Type | Organization
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Legal Business Name | MAPLE LAKE ACADEMY
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Dates
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Enumeration Date | 05/02/2012
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Last Update Date | 05/02/2012
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Provider Practice Location Address
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Address Line | 6155 S 2400 W
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City | SPANISH FORK
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State | UT
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Zip | 84660-4606
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Country | US
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Telephone | 801-798-7700
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Fax |
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Provider Business Mailing Address
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Address Line | 6155 S 2400 W
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City | SPANISH FORK
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State | UT
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Zip | 84660-4606
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Country | US
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Telephone | 801-798-7700
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MARGO L VANE
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Credential |
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Telephone | 801-798-7700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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License Number | 18290
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License Number State | UT
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