Healthcare Provider Details

I. General information

NPI: 1710966437
Provider Name (Legal Business Name): BLAKE BEECHER PHD.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 S MAIN ST SUITE 300
SALT LAKE CITY UT
84101-3176
US

IV. Provider business mailing address

242 CONSTITUTION WAY
NSL UT
84054-1608
US

V. Phone/Fax

Practice location:
  • Phone: 801-536-6500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number349081-3501
License Number StateUT

VII. Legacy identifiers

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

# 1
Identifier682027
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerDESERET MUTUAL
# 2
Identifier107003582101
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerINTERMOUNTAIN HEALTH CARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: