Healthcare Provider Details

I. General information

NPI: 1720322084
Provider Name (Legal Business Name): ASSOCIATION OF LYMPHATIC THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11075 S STATE STREET BLDG. #35
SANDY UT
84070
US

IV. Provider business mailing address

11075 S STATE STREET BLDG. #35
SANDY UT
84070
US

V. Phone/Fax

Practice location:
  • Phone: 801-990-1990
  • Fax:
Mailing address:
  • Phone: 801-990-1990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number278061-2401
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7617767-4701
License Number StateUT

VIII. Authorized Official

Name: MS. GRETCHEN GIVONE
Title or Position: DIRECTOR
Credential: L.M.T., C.D.T.
Phone: 801-990-1959