Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 367293-4201 | UT |
NPI | 1003024761 |
---|---|
Provider Name | Mr. Travis Chamberlain |
First Address | Logan, UT 84321-7204 |
Second Address | Logan, UT 84321-4520 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/05/2007 |
Last Update Date | 08/07/2007 |