Provider Demographics
NPI:1609602374
Name:MERRITT, MCKENNA
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
Last Name:MERRITT
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 1:919 CALLIE CT
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-0165
Mailing Address - Country:US
Mailing Address - Phone:801-923-3537
Mailing Address - Fax:801-753-0744
Practice Address - Street 1:12272 S 800 E
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9789
Practice Address - Country:US
Practice Address - Phone:801-923-3537
Practice Address - Fax:801-753-0744
Is Sole Proprietor?:No
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTBACB1111379106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician