Healthcare Provider Details

I. General information

NPI: 1407053614
Provider Name (Legal Business Name): MONICA ANN FREDERICK MSPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SLC UT
84132-0001
US

IV. Provider business mailing address

PO BOX 510721
SLC UT
84151-0721
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2121
  • Fax:
Mailing address:
  • Phone: 801-587-6872
  • Fax: 801-587-6675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number5287498-2401
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: