Healthcare Provider Details

I. General information

NPI: 1407013402
Provider Name (Legal Business Name): BRIAN COATS RIEDESEL PH.D., B.CE.T.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S 1460 E ROOM 426 - COUNSELING CENTER
SALT LAKE CITY UT
84112-9099
US

IV. Provider business mailing address

201 S 1460 E ROOM 426 - COUNSELING CENTER
SALT LAKE CITY UT
84112-9099
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-6826
  • Fax:
Mailing address:
  • Phone: 801-581-6826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1122822501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: