Provider Demographics
NPI:1669985669
Name:HAMM, MICHAEL RAYMOND JR
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAYMOND
Last Name:HAMM
Suffix:JR
Gender:M
Credentials:
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 461
Mailing Address - Street 2:
Mailing Address - City:MORONI
Mailing Address - State:UT
Mailing Address - Zip Code:84646-0461
Mailing Address - Country:US
Mailing Address - Phone:435-445-5200
Mailing Address - Fax:435-445-5201
Practice Address - Street 1:21360 NORTH 1450 EAST
Practice Address - Street 2:
Practice Address - City:MORONI
Practice Address - State:UT
Practice Address - Zip Code:84646461
Practice Address - Country:US
Practice Address - Phone:435-445-5200
Practice Address - Fax:435-445-5201
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1235458555Medicaid