Provider Demographics
NPI:1629738281
Name:LUTHY, BRENNA SUE
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:SUE
Last Name:LUTHY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 N 180 W
Mailing Address - Street 2:
Mailing Address - City:EPHRAIM
Mailing Address - State:UT
Mailing Address - Zip Code:84627-2130
Mailing Address - Country:US
Mailing Address - Phone:435-283-0164
Mailing Address - Fax:
Practice Address - Street 1:66 N 180 W
Practice Address - Street 2:
Practice Address - City:EPHRAIM
Practice Address - State:UT
Practice Address - Zip Code:84627-2130
Practice Address - Country:US
Practice Address - Phone:435-283-0164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-23
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children