Basic Information
| Provider Information | |||||||||
| NPI: | 1740468768 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAUL | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | BLAKE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.A., L.M.F.T. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 867 | ||||||||
| Address2: | |||||||||
| City: | PRICE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 845010867 | ||||||||
| 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: | 01/31/2008 | ||||||||
| LastUpdateDate: | 09/21/2018 | ||||||||
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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 | 106H00000X | MFC46551 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 10822129-3902 | UT | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | MFC46551 | 01 | CA | BBS | OTHER |