Healthcare Provider Details

I. General information

NPI: 1356997753
Provider Name (Legal Business Name): BROOKELYN MOELLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2019
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12222 S 1000 E STE 3
DRAPER UT
84020-3203
US

IV. Provider business mailing address

12222 S 1000 E STE 3
DRAPER UT
84020-3203
US

V. Phone/Fax

Practice location:
  • Phone: 801-987-3592
  • Fax:
Mailing address:
  • Phone: 801-987-3592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number12974311-2506
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: