Basic Information
| Provider Information | |||||||||
| NPI: | 1033573191 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF UTAH PEDIATRIC BEHAVIORAL HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEUROSTIMULATION CLINIC - PEDIATRIC ADOLESCENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 413021 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841413021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015876336 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 501 S CHIPETA WAY | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841081222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015876336 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2016 | ||||||||
| LastUpdateDate: | 04/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | ZUBIETA | ||||||||
| AuthorizedOfficialFirstName: | JON KAR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DEPARTMENT CHAIR | ||||||||
| AuthorizedOfficialTelephone: | 8015876336 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF UTAH PEDIATRIC BEHAVIORAL HEALTH SERVICES | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0008X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neuromuscular Medicine | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.