Provider Demographics
NPI:1306388178
Name:GUDIEL, ELIZABETH (BCBA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:GUDIEL
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:SANDOVAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11506 S WATERSIDE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-7937
Mailing Address - Country:US
Mailing Address - Phone:801-471-6361
Mailing Address - Fax:
Practice Address - Street 1:12222 S 1000 E STE 4
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-3203
Practice Address - Country:US
Practice Address - Phone:801-471-6361
Practice Address - Fax:801-753-0397
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-10
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-14-9529103K00000X
UT12215360-2506103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst