Healthcare Provider Details

I. General information

NPI: 1790238145
Provider Name (Legal Business Name): UNIVERSITY OF UTAH LIFE SKILLS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 S ARAPEEN DR STE 200
SALT LAKE CITY UT
84108-1216
US

IV. Provider business mailing address

540 S ARAPEEN DR STE 200
SALT LAKE CITY UT
84108-1216
US

V. Phone/Fax

Practice location:
  • Phone: 801-585-6837
  • Fax:
Mailing address:
  • Phone: 801-585-6837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number9819526-4201
License Number StateUT

VIII. Authorized Official

Name: MS. AUBRIANNE SQUIRE
Title or Position: OCCUPATIONAL THERAPIST
Credential: MOT, OTR/L
Phone: 715-307-0501