Provider Demographics
NPI:1740540095
Name:BEISTLINE, BRIAN CALVIN (LMFT)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:CALVIN
Last Name:BEISTLINE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 N EAST PROMONTORY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-7048
Mailing Address - Country:US
Mailing Address - Phone:801-824-5210
Mailing Address - Fax:
Practice Address - Street 1:240 N EAST PROMONTORY
Practice Address - Street 2:SUITE 200
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-7048
Practice Address - Country:US
Practice Address - Phone:801-824-5210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-21
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT876000308007Medicaid
UT876000308007Medicaid
UT260022408OtherRAILROAD MEDICARE