Provider Demographics
NPI:1629633540
Name:BEARDALL, CHANDA R (AS PSY, AS SC)
Entity Type:Individual
Prefix:
First Name:CHANDA
Middle Name:R
Last Name:BEARDALL
Suffix:
Gender:F
Credentials:AS PSY, AS SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1977 E EVERGREEN AVE APT A
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-3965
Mailing Address - Country:US
Mailing Address - Phone:801-577-5790
Mailing Address - Fax:
Practice Address - Street 1:515 S 700 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2801
Practice Address - Country:US
Practice Address - Phone:801-577-5790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician