Basic Information
| Provider Information | |||||||||
| NPI: | 1609241124 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHRYSALIS-NEVADA INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1443 W 800 N | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | OREM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840572875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016554950 | ||||||||
| FaxNumber: | 8016554954 | ||||||||
| Practice Location | |||||||||
| Address1: | 5595 EQUITY AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895022589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753226060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2015 | ||||||||
| LastUpdateDate: | 12/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | CHRISTENSEN | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | ROBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8016554950 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.