Healthcare Provider Details

I. General information

NPI: 1518893411
Provider Name (Legal Business Name): MADDEX HAROLD PARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 W ALEXANDER ST
WEST VALLEY UT
84119-2037
US

IV. Provider business mailing address

244 N 300 W
AMERICAN FORK UT
84003-1414
US

V. Phone/Fax

Practice location:
  • Phone: 208-908-8923
  • Fax:
Mailing address:
  • Phone: 385-484-9634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-510676
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: