Provider Demographics
NPI:1700550852
Name:BENALLIE, TROY
Entity type:Individual
Prefix:
First Name:TROY
Middle Name:
Last Name:BENALLIE
Suffix:
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 1:23 W 1325 S
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-8240
Mailing Address - Country:US
Mailing Address - Phone:435-233-0465
Mailing Address - Fax:
Practice Address - Street 1:517 W 100 N STE 110
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9826
Practice Address - Country:US
Practice Address - Phone:435-755-6061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT123045813904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist