Healthcare Provider Details

I. General information

NPI: 1114405552
Provider Name (Legal Business Name): BRYANNA FOX MA, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2018
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 S 700 E STE 2A
SALT LAKE CITY UT
84102-2855
US

IV. Provider business mailing address

46 W LESTER AVE UNIT G11
MURRAY UT
84107-7138
US

V. Phone/Fax

Practice location:
  • Phone: 317-615-9454
  • Fax:
Mailing address:
  • Phone: 317-615-9454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-61628
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: