Healthcare Provider Details

I. General information

NPI: 1487161477
Provider Name (Legal Business Name): STEPHANIE OGDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2017
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12222 S 1000 E STE 4
DRAPER UT
84020-3203
US

IV. Provider business mailing address

12222 S 1000 E STE 4
DRAPER UT
84020-3203
US

V. Phone/Fax

Practice location:
  • Phone: 801-518-2763
  • Fax:
Mailing address:
  • Phone: 801-518-2763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number11488543-2506
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: