Provider Demographics
NPI:1669975967
Name:DALZEN, BRENDEN
Entity type:Individual
Prefix:
First Name:BRENDEN
Middle Name:
Last Name:DALZEN
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 1:4735 N THANKSGIVING WAY
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-2936
Mailing Address - Country:US
Mailing Address - Phone:801-310-6880
Mailing Address - Fax:
Practice Address - Street 1:4735 N THANKSGIVING WAY
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-2936
Practice Address - Country:US
Practice Address - Phone:801-310-6880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health