Healthcare Provider Details

I. General information

NPI: 1598629131
Provider Name (Legal Business Name): ASHTON BLACK
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 S 800 W STE 210
PLEASANT GROVE UT
84062-4567
US

IV. Provider business mailing address

919 CALLIE CT
NORTH SALT LAKE UT
84054-0165
US

V. Phone/Fax

Practice location:
  • Phone: 801-923-3537
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-479863
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: