Provider Demographics
NPI:1174981914
Name:HASLAM, AMY (BCBA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:HASLAM
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 S 700 E STE 2A
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2855
Mailing Address - Country:US
Mailing Address - Phone:801-935-4171
Mailing Address - Fax:
Practice Address - Street 1:5160 SUNSET LN
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4230
Practice Address - Country:US
Practice Address - Phone:801-935-5796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-08
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1-17-29630103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst