Healthcare Provider Details

I. General information

NPI: 1093025926
Provider Name (Legal Business Name): JUSTIN NAYLOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2010
Last Update Date: 01/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 S 700 E STE 203
SALT LAKE CITY UT
84107-3075
US

IV. Provider business mailing address

13923 HAYSTACK PEAK CIR
RIVERTON UT
84096-6453
US

V. Phone/Fax

Practice location:
  • Phone: 801-598-0743
  • Fax: 801-606-7445
Mailing address:
  • Phone: 801-598-0743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number287380-3502
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: