Healthcare Provider Details

I. General information

NPI: 1104801620
Provider Name (Legal Business Name): JOHN LAWRENCE MALOUF PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4460 S HIGHLAND DR STE 100
SALT LAKE CITY UT
84124-3550
US

IV. Provider business mailing address

4460 S HIGHLAND DR STE 100
SALT LAKE CITY UT
84124-3550
US

V. Phone/Fax

Practice location:
  • Phone: 801-539-7000
  • Fax:
Mailing address:
  • Phone: 801-539-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number221073392501
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number107339-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: