Healthcare Provider Details

I. General information

NPI: 1043820855
Provider Name (Legal Business Name): MITCHELL THOMAS POWELL BEHAVIOR TECHNICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 W. 1130 S. BUILDING B
OREM UT
84058-2888
US

IV. Provider business mailing address

1140 W. 1130 S. BUILDING B
OREM UT
84058-2888
US

V. Phone/Fax

Practice location:
  • Phone: 801-935-4171
  • Fax: 801-935-4946
Mailing address:
  • Phone: 801-935-4171
  • Fax: 801-935-4946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number10382472-2506
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: