1306388178 NPI number — ELIZABETH GUDIEL BCBA

Table of content: ELIZABETH GUDIEL BCBA (NPI 1306388178)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306388178 NPI number — ELIZABETH GUDIEL BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUDIEL
Provider First Name:
ELIZABETH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SANDOVAL
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306388178
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11506 S WATERSIDE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH JORDAN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84095-7937
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-471-6361
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12222 S 1000 E STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DRAPER
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84020-3203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-471-6361
Provider Business Practice Location Address Fax Number:
801-753-0397
Provider Enumeration Date:
11/10/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-14-9529 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103K00000X , with the licence number: 12215360-2506 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)