Healthcare Provider Details

I. General information

NPI: 1124319223
Provider Name (Legal Business Name): ERIN EARL FORTIN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2011
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 HERITAGE PARK BLVD STE 210
LAYTON UT
84041-5645
US

IV. Provider business mailing address

920 HERITAGE PARK BLVD STE 210
LAYTON UT
84041-5645
US

V. Phone/Fax

Practice location:
  • Phone: 801-683-1062
  • Fax:
Mailing address:
  • Phone: 801-683-1062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12655987-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: