Healthcare Provider Details

I. General information

NPI: 1336093533
Provider Name (Legal Business Name): LOGAN PRUETT
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2026
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 MORRIS AVE STE 100
SALT LAKE CITY UT
84115-3278
US

IV. Provider business mailing address

240 MORRIS AVE STE 100
SALT LAKE CITY UT
84115-3278
US

V. Phone/Fax

Practice location:
  • Phone: 801-935-4171
  • Fax:
Mailing address:
  • Phone: 801-935-4171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: