Healthcare Provider Details

I. General information

NPI: 1770405078
Provider Name (Legal Business Name): BRITTNEY WISE GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2472 S 300 E
SOUTH SALT LAKE UT
84115-2895
US

IV. Provider business mailing address

356 S 900 E UNIT B3
SALT LAKE CITY UT
84102-2796
US

V. Phone/Fax

Practice location:
  • Phone: 801-466-2211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number14299508-4003
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: