MEDICARE: TOTAL THETA WELLNESS

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	363LF0000X	Family Nurse Practitioner	200020-4405	UT

General Provider Information

NPI Number	:	1699105338
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOTAL THETA WELLNESS

Provider Business Mailing Address
First Line	:	8789 S HIGHLAND DR
Second Line	:	SUITE 200
City	:	SANDY
State	:	UT
Zip	:	84093-1600
Country	:	US
Telephone Number	:	801-943-3373
Fax Number	:	801-943-0599

Provider Business Practice Location Address
First Line	:	8789 S HIGHLAND DR
Second Line	:	SUITE 200
City	:	SANDY
State	:	UT
Zip	:	84093-1600
Country	:	US
Telephone Number	:	801-943-3373
Fax Number	:	801-943-0599

Authorized Official
Title or Position	:	OWNER
Name	:	MARTHA SOUTHWICK
Credential	:	FNP-BC
Telephone Number	:	801-943-3373

Provider Enumeration Date	:	11/15/2013
Last Update Date	:	02/19/2014

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