Provider Demographics
NPI:1003283607
Name:SOUVALL, STEPHEN
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:SOUVALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5734 W 13400 S
Mailing Address - Street 2:#300
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-6953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5734 W 13400 S
Practice Address - Street 2:#300
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-6953
Practice Address - Country:US
Practice Address - Phone:801-302-7232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60567578225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist