Healthcare Provider Details

I. General information

NPI: 1114861846
Provider Name (Legal Business Name): MR. DANIEL POULSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2026
Last Update Date: 04/15/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

358 E 1200 N
OREM UT
84057-2712
US

IV. Provider business mailing address

566 S 1600 W
PROVO UT
84601-3915
US

V. Phone/Fax

Practice location:
  • Phone: 801-427-3310
  • Fax:
Mailing address:
  • Phone: 801-427-3310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberF23-97365
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: