=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790745768
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAWRENCE DALTON BEALL PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 W WINCHESTER ST SUITE 101
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84107-5607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-263-6367
-----------------------------------------------------
Fax | 801-263-6370
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10039 COUNTRYWOOD DR
-----------------------------------------------------
City | SANDY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84092-3746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-555-3061
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 270228-2501
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------