1154531309 NPI number — KRIS' CAMP/ THERAPY INTENSIVE PROGRAMS, INC

Table of content: GLADYS YOMARIS GONZALEZ MSW (NPI 1588939888)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154531309 NPI number — KRIS' CAMP/ THERAPY INTENSIVE PROGRAMS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KRIS' CAMP/ THERAPY INTENSIVE PROGRAMS, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154531309
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3359 CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
807-733-0721
Provider Business Mailing Address Fax Number:
807-942-1750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25955 CEDAR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDYLLWILD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92549-5840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-598-7735
Provider Business Practice Location Address Fax Number:
801-942-1750
Provider Enumeration Date:
05/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VAN ISPELEW
Authorized Official First Name:
LIEDY
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT DIRECTOR
Authorized Official Telephone Number:
801-733-0721

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT-0016091 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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