Provider Demographics
NPI:1922606763
Name:HALES, ERIC JEFFREY (LCSW)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:JEFFREY
Last Name:HALES
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:881 W BAXTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8506
Mailing Address - Country:US
Mailing Address - Phone:801-995-9534
Mailing Address - Fax:
Practice Address - Street 1:141 E 5600 S STE 105
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6180
Practice Address - Country:US
Practice Address - Phone:801-995-9534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11743559-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11743559-3501OtherDEPARTMENT OF OCCUPATIONAL AND PROFESSIONAL LICENSING
UT15071335OtherCAQH PROVIDER ID