Provider Demographics
NPI:1538552617
Name:BIRTH, MONICA
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:BIRTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2558 E CUPECOY DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-3243
Mailing Address - Country:US
Mailing Address - Phone:801-673-0060
Mailing Address - Fax:
Practice Address - Street 1:2180 E 4500 S
Practice Address - Street 2:SUITE 150-E
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-4434
Practice Address - Country:US
Practice Address - Phone:801-673-0060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-12
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8693718-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT618605600OtherACS (FECA)