Organization
CTR SUPPORTS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
COBILYNN R DICKINSON (EXECUTIVE DIRECTOR)
(801) 450-3164
Entity
Organization
Contact information
Practice address
10182 S CAMPDEN CT, SOUTH JORDAN, UT 84009-7109
(801) 788-4988
(801) 206-3588
Mailing address
10182 S CAMPDEN CT, SOUTH JORDAN, UT 84009-7109
Taxonomy
Speciality
Code
Description
License number
State
103G00000X
Clinical Neuropsychologist
—
—
103K00000X
Behavior Analyst
—
—
103TB0200X
Cognitive & Behavioral Psychologist
Primary
—
—
103TC0700X
Clinical Psychologist
—
—
103TC2200X
Clinical Child & Adolescent Psychologist
—
—
103TM1800X
Intellectual & Developmental Disabilities Psychologist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12195372
CAQH
—
05
—
1658550246
—
UT
01
—
325706-2501
LICENSE PSYCHOLOGIST
UT
01
—
325706-2506
BEHAVIOR ANALYST
UT
Enumeration date
02/06/2018
Last updated
02/06/2018
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