=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952619397
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEALL PSYCHOLOGICAL SERVICES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2010
-----------------------------------------------------
Last Update Date | 08/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 W WINCHESTER ST SUITE 101
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84107-5607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-897-5474
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 902650
-----------------------------------------------------
City | SANDY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84090-2650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-897-5474
-----------------------------------------------------
Fax | 801-263-6370
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/PRESIDENT
-----------------------------------------------------
Name | LAWRENCE DALTON BEALL
-----------------------------------------------------
Credential | PH,D.
-----------------------------------------------------
Telephone | 801-897-5474
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 270228-2501
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------