Basic Information
| Provider Information | |||||||||
| NPI: | 1821020322 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TALCOTT | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | BA/LSAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | VA MEDICAL CTR | ||||||||
| Address2: | 500 FOOTHILL BLVD | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015821565 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | VA MEDICAL CTR | ||||||||
| Address2: | 500 FOOTHILL BLVD | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015821565 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 369794-6006 | UT | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.