Provider Demographics
NPI:1174508154
Name:BAGLEY, BRENDAN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 N CEDAR HOLLOW BLVD
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-1381
Mailing Address - Country:US
Mailing Address - Phone:801-787-1436
Mailing Address - Fax:
Practice Address - Street 1:1202 N CEDAR HOLLOW BLVD
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-1381
Practice Address - Country:US
Practice Address - Phone:801-787-1436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT486172224012251E1200X, 2251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic