Provider Demographics
NPI:1457325672
Name:BLUTH, TYLER WILSON (MPT)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:WILSON
Last Name:BLUTH
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 W 600 S STE 200
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-2284
Mailing Address - Country:US
Mailing Address - Phone:435-654-5607
Mailing Address - Fax:435-654-2602
Practice Address - Street 1:345 W 600 S STE 200
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-2284
Practice Address - Country:US
Practice Address - Phone:435-654-5607
Practice Address - Fax:435-654-2602
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2921172401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870464264000Medicaid
UTD5927Medicaid