Provider Demographics
NPI:1073164034
Name:SANDBERG, MADALENE ROSE
Entity Type:Individual
Prefix:
First Name:MADALENE
Middle Name:ROSE
Last Name:SANDBERG
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 1:211 N 680 E
Mailing Address - Street 2:
Mailing Address - City:VINEYARD
Mailing Address - State:UT
Mailing Address - Zip Code:84059-5703
Mailing Address - Country:US
Mailing Address - Phone:435-862-4970
Mailing Address - Fax:
Practice Address - Street 1:1111 S 1350 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-3817
Practice Address - Country:US
Practice Address - Phone:801-935-4171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-21
Last Update Date:2019-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician