Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT60567578 | WA |
NPI | 1003283607 |
---|---|
Provider Name | Stephen Souvall |
First Address | Herriman, UT 84096-6953 |
Second Address | Herriman, UT 84096-6953 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2015 |
Last Update Date | 31/08/2015 |