Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 106E00000X | Assistant Behavior Analyst | 11353635-2507 | UT |
N | 106S00000X | Behavior Technician |
NPI | 1043795040 |
---|---|
Provider Name | Mrs. Brenna Lyn Wagner |
First Address | Erda, UT 84074-9799 |
Second Address | Salt Lake City, UT 84102-2855 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/09/2018 |
Last Update Date | 12/07/2019 |