Provider Demographics
NPI:1811154321
Name:HALLAM, CLIVE RUSSELL (LMFT)
Entity type:Individual
Prefix:
First Name:CLIVE
Middle Name:RUSSELL
Last Name:HALLAM
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:PO BOX 7425
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-0425
Mailing Address - Country:US
Mailing Address - Phone:435-817-0155
Mailing Address - Fax:307-885-5206
Practice Address - Street 1:19 E ABARR DR
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-5436
Practice Address - Country:US
Practice Address - Phone:435-817-0155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLMFT 134101Y00000X
UT8971102-3902106H00000X
CO0001268106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO48800074Medicaid