Provider Demographics
NPI:1194070276
Name:UNIVERSITY OF UTAH
Entity type:Organization
Organization Name:UNIVERSITY OF UTAH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:801-534-7905
Mailing Address - Street 1:450 S 900 E
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-3608
Mailing Address - Country:US
Mailing Address - Phone:801-532-1850
Mailing Address - Fax:801-532-3608
Practice Address - Street 1:450 S 900 E
Practice Address - Street 2:SUITE 300
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2981
Practice Address - Country:US
Practice Address - Phone:801-532-1850
Practice Address - Fax:801-532-3608
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF UTAH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Single Specialty