Provider Demographics
NPI:1699058586
Name:FAMILY CONNECTION CENTER
Entity type:Organization
Organization Name:FAMILY CONNECTION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:WILDE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:801-773-0712
Mailing Address - Street 1:1360 E 1450 S
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-1611
Mailing Address - Country:US
Mailing Address - Phone:801-773-0712
Mailing Address - Fax:801-774-8267
Practice Address - Street 1:875 E HIGHWAY 193
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84040-6544
Practice Address - Country:US
Practice Address - Phone:801-771-4642
Practice Address - Fax:801-774-8267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT17951251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT260022408OtherRAILROAD MEDICARE
UT876000308007Medicaid
UT000055266Medicare UPIN