Provider Demographics
NPI:1528591351
Name:UTTER, MICHAEL R (ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:UTTER
Suffix:
Gender:M
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8940 W KATHLEEN RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-3727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8940 W KATHLEEN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-3727
Practice Address - Country:US
Practice Address - Phone:623-606-7963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-08
Last Update Date:2017-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAT-AT-101773412255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer