Provider Demographics
NPI:1437942752
Name:SLY, CONNOR WAYNE
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:WAYNE
Last Name:SLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5688 KETCH LN
Mailing Address - Street 2:
Mailing Address - City:STANSBURY PK
Mailing Address - State:UT
Mailing Address - Zip Code:84074-8170
Mailing Address - Country:US
Mailing Address - Phone:385-225-7926
Mailing Address - Fax:
Practice Address - Street 1:272 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-2244
Practice Address - Country:US
Practice Address - Phone:435-241-4107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-28
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician