Provider Demographics
NPI:1619223732
Name:HUME, BENJAMIN
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:HUME
Suffix:
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 1:175 W 1400 N
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-6811
Mailing Address - Country:US
Mailing Address - Phone:435-752-5302
Mailing Address - Fax:
Practice Address - Street 1:175 W 1400 N
Practice Address - Street 2:SUITE A
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-6811
Practice Address - Country:US
Practice Address - Phone:435-752-5302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-26
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT390200000XOtherNO INSURANCE, CASH BASIS