Healthcare Provider Details

I. General information

NPI: 1801414743
Provider Name (Legal Business Name): GRAHAM DAUB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 S WAKARA WAY
SALT LAKE CITY UT
84108-1213
US

IV. Provider business mailing address

520 S WAKARA WAY
SALT LAKE CITY UT
84108-1213
US

V. Phone/Fax

Practice location:
  • Phone: 801-585-1620
  • Fax:
Mailing address:
  • Phone: 801-585-1620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11795097-2401
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number11795097-2401
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: