Provider Demographics
NPI:1174158687
Name:SRIPHONGNGARM, VITTAWAT (BCBA)
Entity type:Individual
Prefix:
First Name:VITTAWAT
Middle Name:
Last Name:SRIPHONGNGARM
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12637 S 265 W
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-5400
Mailing Address - Country:US
Mailing Address - Phone:801-998-8428
Mailing Address - Fax:801-407-1611
Practice Address - Street 1:12637 S 265 W
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-5400
Practice Address - Country:US
Practice Address - Phone:801-998-8428
Practice Address - Fax:801-407-1611
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-04
Last Update Date:2023-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1-19-36623103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst