MEDICARE: LILLIAN BOB ADOLPHSON BCBA-D

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	103K00000X	Behavior Analyst	800311-2506	UT
2	104100000X	Social Worker	311800-3503	UT
3	146M00000X	Intermediate Emergency Medical Technician	2022037088	UT
4	103K00000X	Behavior Analyst	1-11-8304

General Provider Information

NPI Number	:	1932467776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILLIAN BOB ADOLPHSON BCBA-D

Provider Business Mailing Address
First Line	:	1789 E LOGAN AVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-2629
Country	:	US
Telephone Number	:	801-550-3546
Fax Number	:

Provider Business Practice Location Address
First Line	:	1789 E LOGAN AVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-2629
Country	:	US
Telephone Number	:	801-550-3546
Fax Number	:

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

Provider Enumeration Date	:	04/30/2012
Last Update Date	:	09/22/2022

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