Basic Information
| Provider Information | |||||||||
| NPI: | 1710208848 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | VIRLOW | ||||||||
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| Credential: | CSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 867 | ||||||||
| Address2: | 105 WEST 100 NORTH | ||||||||
| City: | PRICE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356377200 | ||||||||
| FaxNumber: | 4356372377 | ||||||||
| Practice Location | |||||||||
| Address1: | 575 EAST 100 SOUTH | ||||||||
| Address2: | |||||||||
| City: | PRICE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356372358 | ||||||||
| FaxNumber: | 4356379141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2010 | ||||||||
| LastUpdateDate: | 06/11/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6396608-3502 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.