Provider Demographics
NPI:1659355790
Name:RICCIARDI, JAMES D (PSYD)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:D
Last Name:RICCIARDI
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2454 SHADOW WOOD CIR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-6251
Mailing Address - Country:US
Mailing Address - Phone:801-272-6430
Mailing Address - Fax:
Practice Address - Street 1:1020 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-3176
Practice Address - Country:US
Practice Address - Phone:801-539-7000
Practice Address - Fax:801-539-7050
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT114731-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTR34636OtherMEDICARE ADVANTAGE PLANS
UT107032404101OtherINTERMOUNTAIN HEALTH CARE
UT261754OtherDESERET MUTUAL
UT107032404101OtherINTERMOUNTAIN HEALTH CARE