Provider Demographics
NPI:1639441694
Name:POULSON, DANIEL
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:POULSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 CRYSTAL AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-1704
Mailing Address - Country:US
Mailing Address - Phone:801-631-8147
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:
Is Sole Proprietor?:No
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT6337850OtherAMERICAN COUNSELING ASSOCIATION