Healthcare Provider Details

I. General information

NPI: 1962029322
Provider Name (Legal Business Name): MELISSA RETALLICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 E 4500 S STE A34
MURRAY UT
84107-2710
US

IV. Provider business mailing address

782 SAGE DR
MORGAN UT
84050-8714
US

V. Phone/Fax

Practice location:
  • Phone: 801-771-0273
  • Fax: 801-771-0221
Mailing address:
  • Phone: 385-439-9730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: