Provider Demographics
NPI:1659914406
Name:HASLAM, BENJAMIN BARRET
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:BARRET
Last Name:HASLAM
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 1:736 S 180 W
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:UT
Mailing Address - Zip Code:84737-2317
Mailing Address - Country:US
Mailing Address - Phone:435-619-4170
Mailing Address - Fax:
Practice Address - Street 1:1055 E SR 9
Practice Address - Street 2:
Practice Address - City:VIRGIN
Practice Address - State:UT
Practice Address - Zip Code:84779-5025
Practice Address - Country:US
Practice Address - Phone:435-619-4170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10444176-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty