Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 10279444-4201 | UT |
NPI | 1003337585 |
---|---|
Provider Name | Mark Powell |
First Address | Salt Lake City, UT 84106-2937 |
Second Address | Salt Lake City, UT 84124-1300 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/07/2017 |
Last Update Date | 05/07/2017 |