Provider Demographics
NPI:1073809984
Name:BLACKHAM, COLTON LAMONT
Entity Type:Individual
Prefix:
First Name:COLTON
Middle Name:LAMONT
Last Name:BLACKHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 461
Mailing Address - Street 2:21260 N 1450 E
Mailing Address - City:MORONI
Mailing Address - State:UT
Mailing Address - Zip Code:84646-0461
Mailing Address - Country:US
Mailing Address - Phone:435-445-5200
Mailing Address - Fax:435-445-5201
Practice Address - Street 1:21260 N 1450 E
Practice Address - Street 2:
Practice Address - City:MORONI
Practice Address - State:UT
Practice Address - Zip Code:84646-0461
Practice Address - Country:US
Practice Address - Phone:435-445-5200
Practice Address - Fax:435-445-5201
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor