Provider Demographics
NPI:1104801620
Name:MALOUF, JOHN LAWRENCE (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LAWRENCE
Last Name:MALOUF
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4460 S HIGHLAND DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3550
Mailing Address - Country:US
Mailing Address - Phone:801-539-7000
Mailing Address - Fax:
Practice Address - Street 1:4460 S HIGHLAND DR STE 100
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-3550
Practice Address - Country:US
Practice Address - Phone:801-539-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT221073392501103TC0700X
UT107339-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTR34637OtherMEDICARE ADVANTAGE
UT261751OtherDESERET MUTUAL
UT942938348MA5OtherEDUCATORS MUTUAL
UT1007001402101OtherINTERMOUNTAIN HEALTH CARE
UTR34637Medicare UPIN
UTU000073811Medicare PIN
UT942938348MA5OtherEDUCATORS MUTUAL