Provider Demographics
NPI:1730932484
Name:GODFREY, BRIAN (MT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:GODFREY
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7591 S UNION PARK AVE APT D312
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-2985
Mailing Address - Country:US
Mailing Address - Phone:801-618-7755
Mailing Address - Fax:
Practice Address - Street 1:7591 S UNION PARK AVE APT D312
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2985
Practice Address - Country:US
Practice Address - Phone:801-618-7755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist