Provider Demographics
NPI:1548342553
Name:LDS FAMILY SERVICES
Entity type:Organization
Organization Name:LDS FAMILY SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:GLADE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-969-4181
Mailing Address - Street 1:5698 WEST GLEN EAGLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84128
Mailing Address - Country:US
Mailing Address - Phone:801-969-4181
Mailing Address - Fax:801-969-1291
Practice Address - Street 1:5698 WEST GLEN EAGLE DRIVE
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84128
Practice Address - Country:US
Practice Address - Phone:801-969-4181
Practice Address - Fax:801-969-1291
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LDS FAMILY SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-19
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057729Medicare ID - Type Unspecified