Healthcare Provider Details

I. General information

NPI: 1346557428
Provider Name (Legal Business Name): RYAN MICHALE BALAGNA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2010
Last Update Date: 09/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 E 1200 S STE 201
OREM UT
84058-6904
US

IV. Provider business mailing address

363 E 1200 S STE 201
OREM UT
84058-6904
US

V. Phone/Fax

Practice location:
  • Phone: 801-224-2313
  • Fax: 801-224-4475
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number71334162501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: