Provider Demographics
NPI:1487199295
Name:MARRIOTT, EMILY MORGAN
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:MORGAN
Last Name:MARRIOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:MORGAN
Other - Last Name:MARRIOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:66 S 1ST W
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1815
Mailing Address - Country:US
Mailing Address - Phone:253-508-9472
Mailing Address - Fax:
Practice Address - Street 1:36 WINN DR STE 100
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5277
Practice Address - Country:US
Practice Address - Phone:208-356-0174
Practice Address - Fax:208-356-0176
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-4834225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant