Provider Demographics
NPI:1467513713
Name:WILLARDSON, DEBRA (ATC)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:WILLARDSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 E SOUTH CAMPUS DR
Mailing Address - Street 2:ATHELTICS DEPT.
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84112-0900
Mailing Address - Country:US
Mailing Address - Phone:801-581-4836
Mailing Address - Fax:801-585-5005
Practice Address - Street 1:1825 E SOUTH CAMPUS DR
Practice Address - Street 2:ATHLETICS DEPT.
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-0900
Practice Address - Country:US
Practice Address - Phone:801-581-4836
Practice Address - Fax:801-585-5005
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1216584810246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT2255A2300XOtherATHLETIC TRAINER