Provider Demographics
NPI:1306915541
Name:UTAH VALLEY FAMILY SUPPORT CENTER INC
Entity type:Organization
Organization Name:UTAH VALLEY FAMILY SUPPORT CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:M
Authorized Official - Last Name:MITSUDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-229-1181
Mailing Address - Street 1:1255 N 1200 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-2445
Mailing Address - Country:US
Mailing Address - Phone:801-229-1181
Mailing Address - Fax:801-229-2787
Practice Address - Street 1:1255 N 1200 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-2445
Practice Address - Country:US
Practice Address - Phone:801-229-1181
Practice Address - Fax:801-229-2787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT114171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT788007788265Medicaid