Provider Demographics
NPI:1699084228
Name:OUTBACK THERAPEUTIC EXPEDITIONS
Entity type:Organization
Organization Name:OUTBACK THERAPEUTIC EXPEDITIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANNINE
Authorized Official - Middle Name:
Authorized Official - Last Name:THALMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-766-3933
Mailing Address - Street 1:50 N 200 E
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-1812
Mailing Address - Country:US
Mailing Address - Phone:801-766-3933
Mailing Address - Fax:801-766-3932
Practice Address - Street 1:50 N 200 E
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-1812
Practice Address - Country:US
Practice Address - Phone:801-766-3933
Practice Address - Fax:801-766-3932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-30
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT17992322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children