Provider Demographics
NPI:1518604248
Name:HENDARTO, AUDREY TETRYANA HERU
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:TETRYANA HERU
Last Name:HENDARTO
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 1:344 E 100 S STE 301
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:344 E 100 S STE 301
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84111-1727
Practice Address - Country:US
Practice Address - Phone:801-428-4257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-15
Last Update Date:2022-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician