Provider Demographics
NPI:1558502385
Name:GOLLEY, THERESA ANN (OTD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:GOLLEY
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1144 SANDTRAP CIR
Mailing Address - Street 2:
Mailing Address - City:N SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-3324
Mailing Address - Country:US
Mailing Address - Phone:801-558-7050
Mailing Address - Fax:
Practice Address - Street 1:3845 W 4700 S
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84118-3454
Practice Address - Country:US
Practice Address - Phone:801-840-4360
Practice Address - Fax:801-840-4399
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-06
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6604772-4201225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics