Provider Demographics
NPI:1528306446
Name:LIFESTAR SALT LAKE, LLC
Entity type:Organization
Organization Name:LIFESTAR SALT LAKE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CSAT
Authorized Official - Phone:801-262-2400
Mailing Address - Street 1:151 E 5600 S
Mailing Address - Street 2:#204
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6181
Mailing Address - Country:US
Mailing Address - Phone:801-262-2400
Mailing Address - Fax:801-262-9991
Practice Address - Street 1:151 E 5600 S
Practice Address - Street 2:#204
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6181
Practice Address - Country:US
Practice Address - Phone:801-262-2400
Practice Address - Fax:801-262-9991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT123039-3501251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health