Provider Demographics
NPI:1780208512
Name:MANU, CALLISSA CANDALOT (BCBA)
Entity type:Individual
Prefix:
First Name:CALLISSA
Middle Name:CANDALOT
Last Name:MANU
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:CALLISSA
Other - Middle Name:
Other - Last Name:CANDALOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3442 S 4300 W
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-1816
Mailing Address - Country:US
Mailing Address - Phone:801-541-0283
Mailing Address - Fax:
Practice Address - Street 1:3442 S 4300 W
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-1816
Practice Address - Country:US
Practice Address - Phone:801-541-0283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
UT14224191-2506103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty