Healthcare Provider Details

I. General information

NPI: 1235513789
Provider Name (Legal Business Name): EMMA AHERN BUCKLEY ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 ALBION VILLAGE WAY
SANDY UT
84070-4013
US

IV. Provider business mailing address

90 ALBION VILLAGE WAY
SANDY UT
84070-4013
US

V. Phone/Fax

Practice location:
  • Phone: 801-619-3670
  • Fax: 801-619-3679
Mailing address:
  • Phone: 801-619-3670
  • Fax: 801-619-3679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12072644-2401
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number104.0113073
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: