Healthcare Provider Details

I. General information

NPI: 1851934889
Provider Name (Legal Business Name): CHARISSA DEVLIN BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 05/02/2020
Certification Date: 05/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6910 S HIGHLAND DR
COTTONWOOD HEIGHTS UT
84121-3060
US

IV. Provider business mailing address

6910 S HIGHLAND DR
COTTONWOOD HEIGHTS UT
84121-3060
US

V. Phone/Fax

Practice location:
  • Phone: 928-637-5144
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-40139
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: