Healthcare Provider Details

I. General information

NPI: 1780126300
Provider Name (Legal Business Name): ADAM BENJAMIN WATANABE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2016
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 S HIGHLAND DR
SALT LAKE CITY UT
84121-1359
US

IV. Provider business mailing address

5800 S HIGHLAND DR
SALT LAKE CITY UT
84121-1359
US

V. Phone/Fax

Practice location:
  • Phone: 801-272-9980
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: