Healthcare Provider Details

I. General information

NPI: 1063344091
Provider Name (Legal Business Name): TREVOR WILTZ DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 S WAKARA WAY
SALT LAKE CITY UT
84108-1200
US

IV. Provider business mailing address

2765 S IMPERIAL ST
SALT LAKE CITY UT
84106-3642
US

V. Phone/Fax

Practice location:
  • Phone: 801-587-7109
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14286753-2401
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: