Healthcare Provider Details

I. General information

NPI: 1730017161
Provider Name (Legal Business Name): MARK WENDELBOE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: REBECCA WENDELBOE

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1273 N 2710 W
PROVO UT
84601-8287
US

IV. Provider business mailing address

1890 W ALEXANDER ST
WEST VALLEY UT
84119-2037
US

V. Phone/Fax

Practice location:
  • Phone: 208-908-8923
  • Fax:
Mailing address:
  • Phone: 208-908-8923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-16-535065
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: