Provider Demographics
NPI:1336699453
Name:GIFFORD, SHEA (LMT)
Entity Type:Individual
Prefix:
First Name:SHEA
Middle Name:
Last Name:GIFFORD
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1488 WESTBURY WAY APT H
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-4907
Mailing Address - Country:US
Mailing Address - Phone:435-592-3475
Mailing Address - Fax:
Practice Address - Street 1:193 E FORT UNION BLVD STE 203
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-5543
Practice Address - Country:US
Practice Address - Phone:435-592-3475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-12
Last Update Date:2023-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-2844225700000X
UT8269416-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDMAS-2844OtherSTATE LICENSE
UT8269416-4701OtherSTATE LICENSE