Provider Demographics
NPI:1639400880
Name:CONDIE, BRANDON E (LPC, NCC, BCBA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:E
Last Name:CONDIE
Suffix:
Gender:M
Credentials:LPC, NCC, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 S STATE ST
Mailing Address - Street 2:#510
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1535
Mailing Address - Country:US
Mailing Address - Phone:801-634-7965
Mailing Address - Fax:
Practice Address - Street 1:570 E 1400 S
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-7714
Practice Address - Country:US
Practice Address - Phone:801-634-7965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6148541-6004101YP2500X
ORC2057101YP2500X
UT1-09-5786103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst