Basic Information
| Provider Information | |||||||||
| NPI: | 1891898045 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHRYSALIS UTAH, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHRYSALIS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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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: | 1443 W 800 N | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | OREM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840572875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016554950 | ||||||||
| FaxNumber: | 8016554954 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHRISTENSEN | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | ROBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8016554950 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MMHC | ||||||||
| NPICertificationDate: | 05/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 320900000X | UT | Y | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 788007788140 | 05 | UT | MEDICAID |