Provider Demographics
NPI:1730251844
Name:DYBREAK BEHAVIORAL HEALTHCARE
Entity type:Organization
Organization Name:DYBREAK BEHAVIORAL HEALTHCARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FILLMORE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-451-4843
Mailing Address - Street 1:PO BOX 1036
Mailing Address - Street 2:117 WEST 200 SOUTH
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-1036
Mailing Address - Country:US
Mailing Address - Phone:801-451-4843
Mailing Address - Fax:801-451-2839
Practice Address - Street 1:117 WEST 200 SOUTH
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-1036
Practice Address - Country:US
Practice Address - Phone:801-451-4843
Practice Address - Fax:801-451-2839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty