Healthcare Provider Details

I. General information

NPI: 1578102091
Provider Name (Legal Business Name): AMELIE JOY BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2020
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6910 S HIGHLAND DR
COTTONWOOD HEIGHTS UT
84121-3060
US

IV. Provider business mailing address

2260 S 800 E APT 3
SALT LAKE CITY UT
84106-1879
US

V. Phone/Fax

Practice location:
  • Phone: 800-434-8923
  • Fax:
Mailing address:
  • Phone: 262-492-9570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number13561383-2506
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: