Provider Demographics
NPI:1033675707
Name:TRUBY, THEODORE NICKOLAS (RBT)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:NICKOLAS
Last Name:TRUBY
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 W PONDEROSA LN
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-9241
Mailing Address - Country:US
Mailing Address - Phone:940-923-6283
Mailing Address - Fax:
Practice Address - Street 1:515 S 700 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2801
Practice Address - Country:US
Practice Address - Phone:940-923-6283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTRBT-18-73731106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician