Provider Demographics
NPI:1467085282
Name:SUPRISE, ELLA
Entity Type:Individual
Prefix:
First Name:ELLA
Middle Name:
Last Name:SUPRISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELLA
Other - Middle Name:
Other - Last Name:MCFADDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:928 W 300 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-2513
Mailing Address - Country:US
Mailing Address - Phone:801-362-6352
Mailing Address - Fax:
Practice Address - Street 1:6910 S HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84121-3060
Practice Address - Country:US
Practice Address - Phone:800-434-8923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician