MEDICARE: WASATCH SPEECH & LANGUAGE CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	110090-4102	UT

General Provider Information

NPI Number	:	1063438620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WASATCH SPEECH & LANGUAGE CENTER

Provider Business Mailing Address
First Line	:	PO BOX 307
Second Line	:
City	:	BOUNTIFUL
State	:	UT
Zip	:	84011-0307
Country	:	US
Telephone Number	:	888-700-6907
Fax Number	:	801-294-6917

Provider Business Practice Location Address
First Line	:	2120 E 3900 S
Second Line	:	SUITE 100
City	:	HOLLADAY
State	:	UT
Zip	:	84124-1771
Country	:	US
Telephone Number	:	801-308-0400
Fax Number	:	801-308-0401

Authorized Official
Title or Position	:	OWNER
Name	:	MR. THOMAS GURRISTER
Credential	:	MS CCC
Telephone Number	:	801-308-0400

Provider Enumeration Date	:	07/15/2006
Last Update Date	:	08/22/2020

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Directions to “WASATCH SPEECH & LANGUAGE CENTER ” Practice Location

Language	Start Address	Practice Location

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