=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609909134
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLOMQUIST HALE CONSULTING GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 860 E 4500 S STE 202
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84107-3014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-262-9619
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 860 E 4500 S STE 202
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84107-3014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-262-9619
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | BRENT HALE
-----------------------------------------------------
Credential | PH.D
-----------------------------------------------------
Telephone | 801-262-9619
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 122843-3501
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------