Provider Demographics
NPI:1417309063
Name:MOULTON, SHAYLA (PTA)
Entity Type:Individual
Prefix:
First Name:SHAYLA
Middle Name:
Last Name:MOULTON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 W 400 N STE 6
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-1951
Mailing Address - Country:US
Mailing Address - Phone:775-217-1553
Mailing Address - Fax:
Practice Address - Street 1:527 W 400 N STE 6
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-1951
Practice Address - Country:US
Practice Address - Phone:775-217-1553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9421703-2402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant