Provider Demographics
NPI:1346269917
Name:WATERBURY, JOHN ORVILLE (LPC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ORVILLE
Last Name:WATERBURY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 BOULTON WAY
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6471
Mailing Address - Country:US
Mailing Address - Phone:801-298-2334
Mailing Address - Fax:801-298-2334
Practice Address - Street 1:52 BOULTON WAY
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6471
Practice Address - Country:US
Practice Address - Phone:801-298-2334
Practice Address - Fax:801-298-2334
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT138013-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional