Provider Demographics
NPI:1790745768
Name:BEALL, LAWRENCE DALTON (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:DALTON
Last Name:BEALL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:LARRY
Other - Middle Name:
Other - Last Name:BEALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:10039 COUNTRYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-3746
Mailing Address - Country:US
Mailing Address - Phone:801-555-3061
Mailing Address - Fax:
Practice Address - Street 1:32 W WINCHESTER ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-5607
Practice Address - Country:US
Practice Address - Phone:801-263-6367
Practice Address - Fax:801-263-6370
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT270228-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical