Provider Demographics
NPI:1063012409
Name:OTIENO, RISPAH
Entity Type:Individual
Prefix:
First Name:RISPAH
Middle Name:
Last Name:OTIENO
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 1:4460 S HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:MILLCREEK
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3543
Mailing Address - Country:US
Mailing Address - Phone:888-949-4864
Mailing Address - Fax:
Practice Address - Street 1:100 S 1000 W
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-4010
Practice Address - Country:US
Practice Address - Phone:888-949-4864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106S00000X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician