Provider Demographics
NPI:1790372159
Name:ANDELIN, RICHARD (LCMHC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:ANDELIN
Suffix:
Gender:M
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 W 500 S STE 104
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6203
Mailing Address - Country:US
Mailing Address - Phone:801-930-0320
Mailing Address - Fax:
Practice Address - Street 1:106 W 500 S STE 104
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6203
Practice Address - Country:US
Practice Address - Phone:801-930-0320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT72301116004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health