Provider Demographics
NPI:1033308317
Name:CHIDESTER, CLINTON RICHARD (PHD)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:RICHARD
Last Name:CHIDESTER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 EAST 550 NORTH
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-2840
Mailing Address - Country:US
Mailing Address - Phone:801-698-8755
Mailing Address - Fax:
Practice Address - Street 1:96 NORTH 500 WEST
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:74010-2840
Practice Address - Country:US
Practice Address - Phone:801-698-8755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1121493902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist