Provider Demographics
NPI:1164886529
Name:VAN VALKENBURG-THORUM, AMANDA (LMT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:VAN VALKENBURG-THORUM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9506 S ALBION CIR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-3025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:626 N 1000 W
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-5000
Practice Address - Country:US
Practice Address - Phone:801-638-8525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7496761-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist