Provider Demographics
NPI:1568220333
Name:LARSON, BROCKEN D (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:BROCKEN
Middle Name:D
Last Name:LARSON
Suffix:
Gender:M
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 W 425 S
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-7349
Mailing Address - Country:US
Mailing Address - Phone:385-439-4446
Mailing Address - Fax:
Practice Address - Street 1:10404 S 1055 W
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-1514
Practice Address - Country:US
Practice Address - Phone:801-855-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12068508-2506103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst