Provider Demographics
NPI:1588938096
Name:CHILES PSYCHOLOGICAL SERVICES INC
Entity type:Organization
Organization Name:CHILES PSYCHOLOGICAL SERVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:AUSTIN
Authorized Official - Last Name:CHILES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:801-774-8888
Mailing Address - Street 1:1477 N 2000 W
Mailing Address - Street 2:SUITE C
Mailing Address - City:CLINTON
Mailing Address - State:UT
Mailing Address - Zip Code:84015-8638
Mailing Address - Country:US
Mailing Address - Phone:801-774-8888
Mailing Address - Fax:801-825-8519
Practice Address - Street 1:1477 N 2000 W
Practice Address - Street 2:SUITE C
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015-8638
Practice Address - Country:US
Practice Address - Phone:801-774-8888
Practice Address - Fax:801-825-8519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-01
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT376639-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1538486097Medicaid
UTU000075833Medicare PIN