Healthcare Provider Details

I. General information

NPI: 1730857285
Provider Name (Legal Business Name): GRAYDON DAN LARSEN MOT, OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5284 S COMMERCE DR STE C214
MURRAY UT
84107-5568
US

IV. Provider business mailing address

859 E JOHNSON WAY DR
SANDY UT
84094-6345
US

V. Phone/Fax

Practice location:
  • Phone: 801-871-5492
  • Fax:
Mailing address:
  • Phone: 801-386-3967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number12814739-4201
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: