=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497005391
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JULIE WILCOX LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2012
-----------------------------------------------------
Last Update Date | 09/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8496 S HARRISON ST
-----------------------------------------------------
City | MIDVALE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84047-3520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-689-1052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 713 W 1300 S
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84104-1634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-689-1052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 6679283-4701
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------