Basic Information
| Provider Information | |||||||||
| NPI: | 1720305204 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ESSEY | ||||||||
| FirstName: | DARYL | ||||||||
| MiddleName: | KEITH | ||||||||
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| Credential: | CPCI | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 867 | ||||||||
| Address2: | 105 WEST 100 NORTH | ||||||||
| City: | PRICE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356377200 | ||||||||
| FaxNumber: | 4356372377 | ||||||||
| Practice Location | |||||||||
| Address1: | 575 WEST 100 SOUTH | ||||||||
| Address2: | |||||||||
| City: | PRICE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356372358 | ||||||||
| FaxNumber: | 4356379141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2010 | ||||||||
| LastUpdateDate: | 06/22/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 7513046-6009 | UT | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | 7513046-6004 | UT | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1 | 05 | UT | MEDICAID |