Provider Demographics
NPI:1376841106
Name:MAIN, BOBBY JOE JR
Entity Type:Individual
Prefix:MR
First Name:BOBBY
Middle Name:JOE
Last Name:MAIN
Suffix:JR
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 1:100 S 1000 W
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-4010
Mailing Address - Country:US
Mailing Address - Phone:435-843-3554
Mailing Address - Fax:435-843-3555
Practice Address - Street 1:100 S 1000 W
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-4010
Practice Address - Country:US
Practice Address - Phone:435-843-3554
Practice Address - Fax:435-843-3555
Is Sole Proprietor?:No
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor