Healthcare Provider Details

I. General information

NPI: 1669220372
Provider Name (Legal Business Name): CHRISTINA MARLENE SUMMERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2024
Last Update Date: 05/08/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 E 1450 S
CLEARFIELD UT
84015-1610
US

IV. Provider business mailing address

1481 DALLAS ST
SYRACUSE UT
84075-9405
US

V. Phone/Fax

Practice location:
  • Phone: 801-728-4326
  • Fax:
Mailing address:
  • Phone: 385-368-3992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number8993761-4003
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: