MEDICARE: MR. JAMES D. RICCIARDI PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	114731-2501	UT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R34636	OTHER	UT	MEDICARE ADVANTAGE PLANS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	107032404101	OTHER	UT	INTERMOUNTAIN HEALTH CARE
3	261754	OTHER	UT	DESERET MUTUAL

General Provider Information

NPI Number	:	1659355790
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES D. RICCIARDI PSY.D.

Provider Business Mailing Address
First Line	:	2454 SHADOW WOOD CIR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-6251
Country	:	US
Telephone Number	:	801-272-6430
Fax Number	:

Provider Business Practice Location Address
First Line	:	1020 S MAIN ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84101-3176
Country	:	US
Telephone Number	:	801-539-7000
Fax Number	:	801-539-7050

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	07/08/2007

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