Provider Demographics
NPI:1932467776
Name:ADOLPHSON, LILLIAN BOB (BCBA-D)
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:BOB
Last Name:ADOLPHSON
Suffix:
Gender:F
Credentials:BCBA-D
Other - Prefix:DR
Other - First Name:SARAH
Other - Middle Name:LILLIAN
Other - Last Name:ADOLPHSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA-D
Mailing Address - Street 1:1789 E LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-2629
Mailing Address - Country:US
Mailing Address - Phone:801-550-3546
Mailing Address - Fax:
Practice Address - Street 1:1789 E LOGAN AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-2629
Practice Address - Country:US
Practice Address - Phone:801-550-3546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT800311-2506103K00000X
UT311800-3503104100000X
UT2022037088146M00000X
1-11-8304103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate