MEDICARE: DEANNA DIBELLA

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	225100000X	Physical Therapist	292666-2401	UT

General Provider Information

NPI Number	:	1619199569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEANNA DIBELLA

Provider Business Mailing Address
First Line	:	1741 LOGAN AVENUE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108
Country	:	US
Telephone Number	:	801-468-8419
Fax Number	:

Provider Business Practice Location Address
First Line	:	1741 E LOGAN AVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-2629
Country	:	US
Telephone Number	:	801-468-8419
Fax Number	:

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

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	03/17/2015

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Directions to “ DEANNA DIBELLA ” Practice Location

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