Healthcare Provider Details

I. General information

NPI: 1881995587
Provider Name (Legal Business Name): BONNIE JO WHITING PT, DPT, CSCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BONNIE JO LUTZ PT, DPT, CSCS

II. Dates (important events)

Enumeration Date: 11/11/2010
Last Update Date: 12/16/2022
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 E RIVERSIDE DR STE 303
ST GEORGE UT
84790-8722
US

IV. Provider business mailing address

617 E RIVERSIDE DR STE 303
ST GEORGE UT
84790-8722
US

V. Phone/Fax

Practice location:
  • Phone: 661-377-1701
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12896081-2401
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number37267
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: