Healthcare Provider Details

I. General information

NPI: 1336779040
Provider Name (Legal Business Name): KYLIE RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2020
Last Update Date: 12/14/2022
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N 1200 E STE 102
LEHI UT
84043-5863
US

IV. Provider business mailing address

1443 W 800 N
OREM UT
84057-2875
US

V. Phone/Fax

Practice location:
  • Phone: 801-655-4950
  • Fax:
Mailing address:
  • Phone: 435-655-4950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number13117625-2506
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: