Provider Demographics
NPI:1700779253
Name:DALLEY, BRYAN J (MED, ACMHC)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:J
Last Name:DALLEY
Suffix:
Gender:M
Credentials:MED, ACMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 W 200 N APT 102
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-6044
Mailing Address - Country:US
Mailing Address - Phone:801-635-5075
Mailing Address - Fax:
Practice Address - Street 1:3585 N UNIVERSITY AVE STE 300
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6611
Practice Address - Country:US
Practice Address - Phone:801-797-1111
Practice Address - Fax:801-996-0158
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT142232426009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health