Healthcare Provider Details

I. General information

NPI: 1932467776
Provider Name (Legal Business Name): LILLIAN BOB ADOLPHSON BCBA-D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARAH LILLIAN ADOLPHSON BCBA-D

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1789 E LOGAN AVE
SALT LAKE CITY UT
84108-2629
US

IV. Provider business mailing address

1789 E LOGAN AVE
SALT LAKE CITY UT
84108-2629
US

V. Phone/Fax

Practice location:
  • Phone: 801-550-3546
  • Fax:
Mailing address:
  • Phone: 801-550-3546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number311800-3503
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code146M00000X
TaxonomyIntermediate Emergency Medical Technician
License Number2022037088
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number800311-2506
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-11-8304
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: