MEDICARE: MARIE LANE TRT

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	226000000X	Recreational Therapist Assistant	10870840-4003	UT

General Provider Information

NPI Number	:	1912761271
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIE LANE TRT

Provider Business Mailing Address
First Line	:	2994 S 1100 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2672
Country	:	US
Telephone Number	:	801-910-6427
Fax Number	:

Provider Business Practice Location Address
First Line	:	4090 W PIONEER PKWY
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84120-2060
Country	:	US
Telephone Number	:	801-397-4400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2024
Last Update Date	:	02/07/2024

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Directions to “ MARIE LANE TRT” Practice Location

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