Provider Demographics
NPI:1417764242
Name:ABA BEDROCK UTAH LLC
Entity type:Organization
Organization Name:ABA BEDROCK UTAH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MAYER
Authorized Official - Middle Name:
Authorized Official - Last Name:KULEFSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-461-0983
Mailing Address - Street 1:10 W BROADWAY FL 7
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-2060
Mailing Address - Country:US
Mailing Address - Phone:347-461-0983
Mailing Address - Fax:
Practice Address - Street 1:10 W BROADWAY FL 7
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-2060
Practice Address - Country:US
Practice Address - Phone:347-461-0983
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty