Healthcare Provider Details

I. General information

NPI: 1780603910
Provider Name (Legal Business Name): SAMUEL J DELONG OTD, OTRL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 11/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1992 W ANTELOPE DR SUITE 1-D
LAYTON UT
84041-4953
US

IV. Provider business mailing address

1992 W ANTELOPE DR SUITE 1-D
LAYTON UT
84041-4953
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-2633
  • Fax: 801-773-1553
Mailing address:
  • Phone: 801-773-2633
  • Fax: 801-773-1553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number6717526-4201
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: