Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XN1300X | Occupational Therapist - Neurorehabilitation | 2793404201 | UT |
NPI | 1972979045 |
---|---|
Provider Name | Greg Wootton |
First Address | Provo, UT 84604-2959 |
Second Address | Draper, UT 84020-5005 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2015 |
Last Update Date | 14/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
NONE | NONE (01) | UT |