Provider Demographics
NPI:1417641960
Name:SEYFRIED, WILLIS R (INTERN)
Entity Type:Individual
Prefix:
First Name:WILLIS
Middle Name:R
Last Name:SEYFRIED
Suffix:
Gender:M
Credentials:INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 S 500 E STE 6
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-6955
Mailing Address - Country:US
Mailing Address - Phone:801-392-0942
Mailing Address - Fax:801-392-0943
Practice Address - Street 1:5300 S 500 E STE 6
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6955
Practice Address - Country:US
Practice Address - Phone:801-392-0942
Practice Address - Fax:801-392-0943
Is Sole Proprietor?:No
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health