Provider Demographics
NPI:1669874350
Name:FAWSON, SARA KAY (RBT)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:KAY
Last Name:FAWSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1585 N 400 E APT 533
Mailing Address - Street 2:
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-7587
Mailing Address - Country:US
Mailing Address - Phone:435-830-1895
Mailing Address - Fax:
Practice Address - Street 1:358 S 700 E STE B307
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2161
Practice Address - Country:US
Practice Address - Phone:801-935-5796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-24
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
UT176758965106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101Y00000XBehavioral Health & Social Service ProvidersCounselor