1740515576 NPI number — ATAC PSYCHOTHERAPY ASSOCIATES INC

Table of content: MR. RANDOLPH PONGTAN CAYABAS PT (NPI 1730423286)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740515576 NPI number — ATAC PSYCHOTHERAPY ASSOCIATES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATAC PSYCHOTHERAPY ASSOCIATES 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:
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:
1740515576
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 E 4500 S
Provider Second Line Business Mailing Address:
SUITE C-150
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84107-4533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-288-0747
Provider Business Mailing Address Fax Number:
801-288-0761

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5005 S 900 E
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84117-5788
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-273-3943
Provider Business Practice Location Address Fax Number:
801-273-3951
Provider Enumeration Date:
10/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
RICHARDS
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
801-273-3943

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  124145-3501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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