Healthcare Provider Details

I. General information

NPI: 1639400880
Provider Name (Legal Business Name): BRANDON E CONDIE LPC, NCC, BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2010
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 E 1400 S
OREM UT
84097-7714
US

IV. Provider business mailing address

29 S STATE ST #510
SALT LAKE CITY UT
84111-1535
US

V. Phone/Fax

Practice location:
  • Phone: 801-634-7965
  • Fax:
Mailing address:
  • Phone: 801-634-7965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6148541-6004
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC2057
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-09-5786
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: