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NPI Code Detail

MEDICARE: GILLIAN BERAN-MARYOTT PT, DPT

MEDICARE: GILLIAN BERAN-MARYOTT PT, DPT
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
1225100000XPhysical Therapist11819269-2401UT

General Provider Information

NPI Number : 1932707635
Entity Type Code : Individual
Provider Name (Legal Business Name) : GILLIAN BERAN-MARYOTT PT, DPT
Provider Business Mailing Address
First Line : 2550 S MAIN ST APT 4309
Second Line :
City : SOUTH SALT LAKE
State : UT
Zip : 84115-3078
Country : US
Telephone Number : 503-896-6080
Fax Number :
Provider Business Practice Location Address
First Line : 165 S 1000 E
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84102-1402
Country : US
Telephone Number : 801-322-5521
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/14/2020
Last Update Date : 10/14/2020

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