Basic Information
| Provider Information | |||||||||
| NPI: | 1467656900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FIELD | ||||||||
| FirstName: | CLINTON | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1350 N 500 E | ||||||||
| Address2: | |||||||||
| City: | LOGAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843412400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357520422 | ||||||||
| FaxNumber: | 4357921615 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 N 500 E | ||||||||
| Address2: | |||||||||
| City: | LOGAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843412400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357520422 | ||||||||
| FaxNumber: | 4357921615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 12/15/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 58050222501 | UT | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 876000528059 | 05 | UT | MEDICAID | 58050222501 | 01 | UT | BCBS | OTHER |