Healthcare Provider Details

I. General information

NPI: 1134985815
Provider Name (Legal Business Name): KATELYN LAAKSONEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2024
Last Update Date: 02/21/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 W 465 N STE 504
PROVIDENCE UT
84332-8014
US

IV. Provider business mailing address

550 W 465 N STE 504
PROVIDENCE UT
84332-8014
US

V. Phone/Fax

Practice location:
  • Phone: 435-535-3677
  • Fax:
Mailing address:
  • Phone: 435-535-3677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13737595-2401
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: