Healthcare Provider Details

I. General information

NPI: 1942123716
Provider Name (Legal Business Name): MODERN INTERVENTION LEARNING ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 N 3200 W
LAYTON UT
84041-8702
US

IV. Provider business mailing address

715 N 3200 W
LAYTON UT
84041-8702
US

V. Phone/Fax

Practice location:
  • Phone: 801-473-7103
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: BROOKLYN SHUMWAY
Title or Position: OWNER
Credential: MA., BCBA, LBA
Phone: 801-473-7103