Healthcare Provider Details

I. General information

NPI: 1770090722
Provider Name (Legal Business Name): MADISON SPENDLOVE BODILY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2017
Last Update Date: 11/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2940 N CHURCH ST STE 303
LAYTON UT
84040-6617
US

IV. Provider business mailing address

515 S 700 E STE 2A
SALT LAKE CITY UT
84102-2855
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number11506292-2507
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: