Healthcare Provider Details

I. General information

NPI: 1568253334
Provider Name (Legal Business Name): REVISION TRAUMA THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2025
Last Update Date: 12/31/2025
Certification Date: 12/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1429 S 550 E STE 230
OREM UT
84097-7798
US

IV. Provider business mailing address

7533 S CENTER VIEW CT # 4758
WEST JORDAN UT
84084-5526
US

V. Phone/Fax

Practice location:
  • Phone: 385-275-2733
  • Fax:
Mailing address:
  • Phone: 385-275-2733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARTINA E BAILEY
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: MSW ,LCSW
Phone: 385-275-2733