Provider Demographics
NPI:1124119425
Name:FORDHAM, MICHAEL READ (PHD)
Entity type:Individual
Prefix:PROF
First Name:MICHAEL
Middle Name:READ
Last Name:FORDHAM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:PROF
Other - First Name:MICHAEL
Other - Middle Name:READ
Other - Last Name:FORDHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:501 CHIPETA WAY
Mailing Address - Street 2:SUITE 1250
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1222
Mailing Address - Country:US
Mailing Address - Phone:801-587-3208
Mailing Address - Fax:801-585-8410
Practice Address - Street 1:501 CHIPETA WAY
Practice Address - Street 2:SUITE 1250
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1222
Practice Address - Country:US
Practice Address - Phone:801-587-3208
Practice Address - Fax:801-585-8410
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT105393-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000001559Medicare PIN