MEDICARE: MICHAEL MCILRATH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1649871112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL MCILRATH

Provider Business Mailing Address
First Line	:	515 S 700 E STE 2A
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-2855
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8913 N SUFFOLK LN
Second Line	:
City	:	EAGLE MOUNTAIN
State	:	UT
Zip	:	84005-4457
Country	:	US
Telephone Number	:	385-250-7745
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2020
Last Update Date	:	11/02/2020

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