Healthcare Provider Details

I. General information

NPI: 1124625637
Provider Name (Legal Business Name): BARRY FELL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2020
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 W CENTER ST
OREM UT
84057-5202
US

IV. Provider business mailing address

870 W CENTER ST
OREM UT
84057-5202
US

V. Phone/Fax

Practice location:
  • Phone: 801-836-9358
  • Fax:
Mailing address:
  • Phone: 801-836-9358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6258352-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: