MEDICARE: MR. THOMAS GURRISTER MS CCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	110090-4102	UT

General Provider Information

NPI Number	:	1073533295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THOMAS GURRISTER MS CCC

Provider Business Mailing Address
First Line	:	PO BOX 307
Second Line	:
City	:	BOUNTIFUL
State	:	UT
Zip	:	84011-0307
Country	:	US
Telephone Number	:	888-700-6907
Fax Number	:	801-294-6917

Provider Business Practice Location Address
First Line	:	2120 E 3900 S
Second Line	:	#100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1771
Country	:	US
Telephone Number	:	801-308-0400
Fax Number	:	801-308-0401

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	07/08/2007

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