Provider Demographics
NPI:1407013402
Name:RIEDESEL, BRIAN COATS (PHD, BCETS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:COATS
Last Name:RIEDESEL
Suffix:
Gender:M
Credentials:PHD, BCETS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S 1460 E
Mailing Address - Street 2:ROOM 426 - COUNSELING CENTER
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84112-9099
Mailing Address - Country:US
Mailing Address - Phone:801-581-6826
Mailing Address - Fax:
Practice Address - Street 1:201 S 1460 E
Practice Address - Street 2:ROOM 426 - COUNSELING CENTER
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-9099
Practice Address - Country:US
Practice Address - Phone:801-581-6826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1122822501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD1800Medicaid
UT876000525706Medicaid
UT876000525706Medicaid