Provider Demographics
NPI:1639484629
Name:HUMBERG, CHRISTIE
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:
Last Name:HUMBERG
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 1:1018 ATHERTON DR
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-3470
Mailing Address - Country:US
Mailing Address - Phone:801-716-2289
Mailing Address - Fax:801-557-3826
Practice Address - Street 1:1018 ATHERTON DR
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-3470
Practice Address - Country:US
Practice Address - Phone:801-716-2289
Practice Address - Fax:801-557-3826
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT739696-8019225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist