Provider Demographics
NPI:1962029322
Name:RETALLICK, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:RETALLICK
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 1:782 SAGE DR
Mailing Address - Street 2:
Mailing Address - City:MORGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84050-8714
Mailing Address - Country:US
Mailing Address - Phone:385-439-9730
Mailing Address - Fax:
Practice Address - Street 1:404 E 4500 S STE A34
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-2710
Practice Address - Country:US
Practice Address - Phone:801-771-0273
Practice Address - Fax:801-771-0221
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-01
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician