Provider Demographics
NPI:1710552724
Name:KIRBY, ANNALISSA KAYTE
Entity Type:Individual
Prefix:
First Name:ANNALISSA
Middle Name:KAYTE
Last Name:KIRBY
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 1:1285 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-3031
Mailing Address - Country:US
Mailing Address - Phone:385-273-9013
Mailing Address - Fax:
Practice Address - Street 1:1140 W 1130 S
Practice Address - Street 2:SUITE B
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058
Practice Address - Country:US
Practice Address - Phone:801-935-4171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician