Healthcare Provider Details

I. General information

NPI: 1629925441
Provider Name (Legal Business Name): SHANTALL CARRASCO GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2026
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 S GUARDSMAN WAY
SALT LAKE CITY UT
84108-1374
US

IV. Provider business mailing address

3737 W 4100 S
WEST VALLEY CITY UT
84120-5543
US

V. Phone/Fax

Practice location:
  • Phone: 888-949-4864
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-520896
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: