Healthcare Provider Details

I. General information

NPI: 1740776426
Provider Name (Legal Business Name): MICAH SLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2018
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6033 FASHION POINT DR
SOUTH OGDEN UT
84403-4847
US

IV. Provider business mailing address

3697 OAKRIDGE DR
BOUNTIFUL UT
84010-5864
US

V. Phone/Fax

Practice location:
  • Phone: 605-271-2690
  • Fax:
Mailing address:
  • Phone: 928-388-8494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number12254646-2506
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: