=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073164034
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADALENE ROSE SANDBERG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2019
-----------------------------------------------------
Last Update Date | 01/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 404 E 4500 S STE A34
-----------------------------------------------------
City | MURRAY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84107-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-771-0273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 475 E 6TH AVE APT 4
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84103-3036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-862-4970
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------