Healthcare Provider Details

I. General information

NPI: 1972746006
Provider Name (Legal Business Name): RICHARD EDWARD HALLAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2009
Last Update Date: 04/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 W 50 N
AMERICAN FORK UT
84003-2265
US

IV. Provider business mailing address

621 N 350 W
AMERICAN FORK UT
84003-1119
US

V. Phone/Fax

Practice location:
  • Phone: 801-756-3664
  • Fax:
Mailing address:
  • Phone: 801-492-1246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5862169-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: