Provider Demographics
NPI:1013342690
Name:HADERLIE, MICHAEL M (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:M
Last Name:HADERLIE
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 1:233 S. PLEASANT GROVE BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062
Mailing Address - Country:US
Mailing Address - Phone:801-785-4622
Mailing Address - Fax:801-785-4623
Practice Address - Street 1:233 S. PLEASANT GROVE BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062
Practice Address - Country:US
Practice Address - Phone:801-785-4622
Practice Address - Fax:801-785-4623
Is Sole Proprietor?:No
Enumeration Date:2013-09-13
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8097827-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist