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NPI Code Detail

MEDICARE: STATE OF UTAH

MEDICARE: STATE OF UTAH
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
1283Q00000XPsychiatric Hospital

General Provider Information

NPI Number : 1811978620
Entity Type Code : Organization
Provider Name (Legal Business Name) : STATE OF UTAH
Provider Business Mailing Address
First Line : PO BOX 270
Second Line :
City : PROVO
State : UT
Zip : 84603-0270
Country : US
Telephone Number : 801-344-4400
Fax Number : 801-344-4225
Provider Business Practice Location Address
First Line : 1300 E CENTER ST
Second Line :
City : PROVO
State : UT
Zip : 84606-3554
Country : US
Telephone Number : 801-344-4400
Fax Number : 801-344-4225
Authorized Official
Title or Position : SUPERINTENDENT
Name : DALLAS EARNSHAW
Credential : APRN
Telephone Number : 801-344-4200
Provider Enumeration Date : 11/09/2005
Last Update Date : 10/09/2024

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1386624625 — MR. DEREK PAUL DAVIS LCSW
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Directions to “STATE OF UTAH ” Practice Location

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