Healthcare Provider Details

I. General information

NPI: 1396280509
Provider Name (Legal Business Name): RJR CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2016
Last Update Date: 12/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 E EDITH AVE
SALT LAKE CITY UT
84111-4502
US

IV. Provider business mailing address

169 E EDITH AVE
SALT LAKE CITY UT
84111-4502
US

V. Phone/Fax

Practice location:
  • Phone: 510-305-9391
  • Fax:
Mailing address:
  • Phone: 510-305-9391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number10194661-2506
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number10194661-2506
License Number StateUT

VIII. Authorized Official

Name: MR. RICHARD JOSE ROBLES
Title or Position: LICENSED BEHAVIOR ANALYST, BCBA
Credential: BCBA, LBA
Phone: 510-305-9391