Individual
BLAKE THOMAS HALLIDAY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LMFT
Contact information
Practice address
5149 S 1500 W, RIVERDALE, UT 84405-3926
(801) 475-0402
(801) 475-7464
Mailing address
5149 S 1500 W, RIVERDALE, UT 84405-3926
(801) 475-0402
(801) 475-7464
Taxonomy
Speciality
Code
Description
License number
State
106H00000X
Marriage & Family Therapist
Primary
5989003-3902
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
260022408
RAILROAD MEDICARE
—
05
—
876000308007
—
UT
Enumeration date
10/18/2006
Last updated
01/04/2010
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