Provider Demographics
NPI:1083278667
Name:VISSER, RICHARD (ASUDC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:VISSER
Suffix:
Gender:M
Credentials:ASUDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 E 5550 S STE 23
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-7038
Mailing Address - Country:US
Mailing Address - Phone:801-475-4673
Mailing Address - Fax:801-528-3392
Practice Address - Street 1:1708 E 5550 S STE 23
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-7038
Practice Address - Country:US
Practice Address - Phone:801-475-4673
Practice Address - Fax:801-528-3392
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT332287-6009101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT332287-6009OtherLICENSE NUMBER