Healthcare Provider Details

I. General information

NPI: 1124904800
Provider Name (Legal Business Name): MELISSA ROHOLT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2025
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 N 200 E
BRIGHAM CITY UT
84302-1303
US

IV. Provider business mailing address

775 N 200 E
BRIGHAM CITY UT
84302-1303
US

V. Phone/Fax

Practice location:
  • Phone: 435-723-7777
  • Fax:
Mailing address:
  • Phone: 435-723-7777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226000000X
TaxonomyRecreational Therapist Assistant
License Number11565772-4003
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code226000000X
TaxonomyRecreational Therapist Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: