Provider Demographics
NPI:1386949055
Name:CLEMENT, BREANNE (BCBA)
Entity type:Individual
Prefix:
First Name:BREANNE
Middle Name:
Last Name:CLEMENT
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 1:28 E 2100 S STE 116
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2356
Mailing Address - Country:US
Mailing Address - Phone:801-916-6678
Mailing Address - Fax:801-505-4639
Practice Address - Street 1:3006 S HIGHLAND DR STE 210
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-6004
Practice Address - Country:US
Practice Address - Phone:801-916-6678
Practice Address - Fax:801-931-2607
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1107392103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst