Provider Demographics
NPI:1003571381
Name:NEW, JOHNNY WESLEY IV
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:WESLEY
Last Name:NEW
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E 5600 S STE 110
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-8153
Mailing Address - Country:US
Mailing Address - Phone:866-375-2437
Mailing Address - Fax:
Practice Address - Street 1:111 E 5600 S STE 110
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-8153
Practice Address - Country:US
Practice Address - Phone:866-375-2437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-02
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst