Provider Demographics
NPI:1740346113
Name:WAILES, RICHARD LEE (LCSW)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:LEE
Last Name:WAILES
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:RIC
Other - Middle Name:
Other - Last Name:WAILES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:2096 ARTHUR DR
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-3237
Mailing Address - Country:US
Mailing Address - Phone:801-808-1072
Mailing Address - Fax:866-882-3907
Practice Address - Street 1:2096 ARTHUR DR
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-3237
Practice Address - Country:US
Practice Address - Phone:801-808-1072
Practice Address - Fax:866-882-3907
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT324302-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTS87497Medicare ID - Type Unspecified