Healthcare Provider Details

I. General information

NPI: 1275204216
Provider Name (Legal Business Name): DIANE KIRBY LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2021
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 N. 400 E STE A,
LOGAN UT
84341
US

IV. Provider business mailing address

1415 N. 400 E STE A,
LOGAN UT
84341
US

V. Phone/Fax

Practice location:
  • Phone: 435-753-2840
  • Fax: 435-787-9422
Mailing address:
  • Phone: 435-753-2840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number6990021-4701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: