MEDICARE: BRENNA GARDNER LMT

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	225700000X	Massage Therapist	4902733-4701	UT

General Provider Information

NPI Number	:	1306326533
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENNA GARDNER LMT

Provider Business Mailing Address
First Line	:	6018 BAYSHORE DR
Second Line	:
City	:	TOOELE
State	:	UT
Zip	:	84074-9065
Country	:	US
Telephone Number	:	801-347-4888
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 S 600 E STE 3B
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1961
Country	:	US
Telephone Number	:	801-359-5149
Fax Number	:

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

Provider Enumeration Date	:	08/16/2018
Last Update Date	:	08/16/2018

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