Provider Demographics
NPI:1205471851
Name:ROSENLOF, BRENNAN JON (RBT)
Entity type:Individual
Prefix:
First Name:BRENNAN
Middle Name:JON
Last Name:ROSENLOF
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 N 1100 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-2443
Mailing Address - Country:US
Mailing Address - Phone:801-891-0404
Mailing Address - Fax:
Practice Address - Street 1:1140 W 1130 S
Practice Address - Street 2:BLDG B
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-2888
Practice Address - Country:US
Practice Address - Phone:801-935-4171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician