MEDICARE: FRESH START BEHAVIORAL SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	2885

General Provider Information

NPI Number	:	1346679396
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRESH START BEHAVIORAL SERVICES

Provider Business Mailing Address
First Line	:	8841 S REDWOOD RD STE D1
Second Line	:
City	:	WEST JORDAN
State	:	UT
Zip	:	84088-9290
Country	:	US
Telephone Number	:	801-566-2468
Fax Number	:	855-787-6818

Provider Business Practice Location Address
First Line	:	8841 S REDWOOD RD STE D1
Second Line	:
City	:	WEST JORDAN
State	:	UT
Zip	:	84088-9290
Country	:	US
Telephone Number	:	801-566-2468
Fax Number	:	855-787-6818

Authorized Official
Title or Position	:	DIRECTOR
Name	:	LANE CANNON PORTER
Credential	:	CMHC
Telephone Number	:	801-566-2468

Provider Enumeration Date	:	11/09/2013
Last Update Date	:	11/09/2013

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