Provider Demographics
NPI:1124328547
Name:SQUIRES, STUART PORTER (LCSW)
Entity type:Individual
Prefix:
First Name:STUART
Middle Name:PORTER
Last Name:SQUIRES
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3761 S BRADE LN
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84780-2742
Mailing Address - Country:US
Mailing Address - Phone:435-313-1712
Mailing Address - Fax:866-351-4226
Practice Address - Street 1:3761 S BRADE LN
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:UT
Practice Address - Zip Code:84780-2742
Practice Address - Country:US
Practice Address - Phone:435-313-1712
Practice Address - Fax:866-351-4226
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT565968235011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical