MEDICARE: BENJAMIN BARRET HASLAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	10444176-3902	UT

General Provider Information

NPI Number	:	1659914406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN BARRET HASLAM

Provider Business Mailing Address
First Line	:	736 S 180 W
Second Line	:
City	:	HURRICANE
State	:	UT
Zip	:	84737-2317
Country	:	US
Telephone Number	:	435-619-4170
Fax Number	:

Provider Business Practice Location Address
First Line	:	1055 E SR 9
Second Line	:
City	:	VIRGIN
State	:	UT
Zip	:	84779-5025
Country	:	US
Telephone Number	:	435-619-4170
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2019
Last Update Date	:	10/24/2019

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Directions to “ BENJAMIN BARRET HASLAM ” Practice Location

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