Provider Demographics
NPI:1225674872
Name:POULSEN, IFAN CASSANDRA
Entity Type:Individual
Prefix:
First Name:IFAN
Middle Name:CASSANDRA
Last Name:POULSEN
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 1:1140 WEST 1130 S
Mailing Address - Street 2:BUILDING B
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-2888
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6910 S HIGHLAND DR STE 1
Practice Address - Street 2:
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84121-3061
Practice Address - Country:US
Practice Address - Phone:801-935-4171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
UT103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst