Provider Demographics
NPI:1023263191
Name:PROFESSIONAL CLINICAL MANAGEMENT
Entity type:Organization
Organization Name:PROFESSIONAL CLINICAL MANAGEMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:F
Authorized Official - Last Name:HYDE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:801-221-0223
Mailing Address - Street 1:1355 N UNIVERSITY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2721
Mailing Address - Country:US
Mailing Address - Phone:801-221-0223
Mailing Address - Fax:801-221-0291
Practice Address - Street 1:1355 N UNIVERSITY AVE STE 200
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2721
Practice Address - Country:US
Practice Address - Phone:801-221-0223
Practice Address - Fax:801-221-0291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT851131532501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty