Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 9343882-2401 | UT |
NPI | 1003200668 |
---|---|
Provider Name | Keegan Marie Granger |
First Address | Salt Lake City, UT 84113-1103 |
Second Address | Salt Lake City, UT 84113-1103 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/03/2015 |
Last Update Date | 22/03/2015 |