Healthcare Provider Details

I. General information

NPI: 1568869899
Provider Name (Legal Business Name): LEGENDARY PEDIATRIC THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2014
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12453 S 265 W STE B
DRAPER UT
84020-5420
US

IV. Provider business mailing address

12453 S 265 W STE B
DRAPER UT
84020-5420
US

V. Phone/Fax

Practice location:
  • Phone: 801-443-7775
  • Fax: 801-447-0107
Mailing address:
  • Phone: 801-443-7775
  • Fax: 801-447-0107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number9554558-4102
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5044485-4201
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number6717450-4201
License Number StateUT

VIII. Authorized Official

Name: BREEANN MILLETTE
Title or Position: BILLING MANAGER
Credential:
Phone: 801-443-7775