Healthcare Provider Details

I. General information

NPI: 1710665740
Provider Name (Legal Business Name): BRYSEN BODILY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2940 N CHURCH ST STE 204
LAYTON UT
84040-6616
US

IV. Provider business mailing address

16255 VENTURA BLVD STE 830
ENCINO CA
91436-2317
US

V. Phone/Fax

Practice location:
  • Phone: 801-935-4171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: