Provider Demographics
NPI:1649706698
Name:FAVERO, BRADEN
Entity type:Individual
Prefix:
First Name:BRADEN
Middle Name:
Last Name:FAVERO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2563 W 5800 S
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-1334
Mailing Address - Country:US
Mailing Address - Phone:801-991-0579
Mailing Address - Fax:
Practice Address - Street 1:2563 W 5800 S
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-1334
Practice Address - Country:US
Practice Address - Phone:801-991-0579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTBACB346416106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician