Provider Demographics
NPI:1710028378
Name:POULTON, JAMES L (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:L
Last Name:POULTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 E 200 S
Mailing Address - Street 2:#303
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2022
Mailing Address - Country:US
Mailing Address - Phone:801-350-0117
Mailing Address - Fax:801-350-9582
Practice Address - Street 1:505 E 200 S
Practice Address - Street 2:SUITE 303
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2090
Practice Address - Country:US
Practice Address - Phone:801-350-0117
Practice Address - Fax:801-350-9582
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT114917-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000007423Medicare PIN