Provider Demographics
NPI:1649486788
Name:ERWIN, BENJAMIN RICHARD (MED)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:RICHARD
Last Name:ERWIN
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:679 WYMOUNT TER
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2040
Mailing Address - Country:US
Mailing Address - Phone:801-378-6055
Mailing Address - Fax:
Practice Address - Street 1:1190 NO. 900 EA.
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84602
Practice Address - Country:US
Practice Address - Phone:801-422-7620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6147387-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist