Provider Demographics
NPI:1487493755
Name:THANADABOUTH, KHIRA ANNE
Entity type:Individual
Prefix:MISS
First Name:KHIRA
Middle Name:ANNE
Last Name:THANADABOUTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:874 N SAPPHIRE ST
Mailing Address - Street 2:
Mailing Address - City:MORGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84050-9917
Mailing Address - Country:US
Mailing Address - Phone:385-229-2758
Mailing Address - Fax:
Practice Address - Street 1:874 N SAPPHIRE ST
Practice Address - Street 2:
Practice Address - City:MORGAN
Practice Address - State:UT
Practice Address - Zip Code:84050-9917
Practice Address - Country:US
Practice Address - Phone:385-229-2758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician