Provider Demographics
NPI:1578305439
Name:ALTA, ERIC ADAM (PHD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:ADAM
Last Name:ALTA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 E BRYAN AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2649
Mailing Address - Country:US
Mailing Address - Phone:617-842-0840
Mailing Address - Fax:
Practice Address - Street 1:750 ROUND VALLEY DR STE 201
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7549
Practice Address - Country:US
Practice Address - Phone:143-564-9768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist