Provider Demographics
NPI:1053706358
Name:MAGELLAN ACADEMY, INC
Entity type:Organization
Organization Name:MAGELLAN ACADEMY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:WIEDERHOLD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:801-794-0318
Mailing Address - Street 1:704 N STATE ROAD 51
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1385
Mailing Address - Country:US
Mailing Address - Phone:801-794-0318
Mailing Address - Fax:801-794-9514
Practice Address - Street 1:704 N STATE ROAD 51
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1385
Practice Address - Country:US
Practice Address - Phone:801-794-0318
Practice Address - Fax:801-794-9514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-02
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children