MEDICARE: BLAKE THOMAS HALLIDAY LMFT

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	106H00000X	Marriage & Family Therapist	5989003-3902	UT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	260022408	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710068473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLAKE THOMAS HALLIDAY LMFT

Provider Business Mailing Address
First Line	:	5149 S 1500 W
Second Line	:
City	:	RIVERDALE
State	:	UT
Zip	:	84405-3926
Country	:	US
Telephone Number	:	801-475-0402
Fax Number	:	801-475-7464

Provider Business Practice Location Address
First Line	:	5149 S 1500 W
Second Line	:
City	:	RIVERDALE
State	:	UT
Zip	:	84405-3926
Country	:	US
Telephone Number	:	801-475-0402
Fax Number	:	801-475-7464

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

Provider Enumeration Date	:	10/18/2006
Last Update Date	:	01/04/2010

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