Provider Demographics
NPI:1497279228
Name:BROWN, JUSTIN GRANT (DPT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:GRANT
Last Name:BROWN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 S 700 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-4251
Mailing Address - Country:US
Mailing Address - Phone:801-709-8744
Mailing Address - Fax:
Practice Address - Street 1:524 W 300 N
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-2667
Practice Address - Country:US
Practice Address - Phone:801-370-9981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10385535-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist