Provider Demographics
NPI:1649771304
Name:ANDERSON, RICKI
Entity Type:Individual
Prefix:
First Name:RICKI
Middle Name:
Last Name:ANDERSON
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 1:1492 W ANTELOPE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-1151
Mailing Address - Country:US
Mailing Address - Phone:801-825-8091
Mailing Address - Fax:801-825-8142
Practice Address - Street 1:1492 W ANTELOPE DR STE 100
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1151
Practice Address - Country:US
Practice Address - Phone:801-825-8091
Practice Address - Fax:801-825-8142
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10626884-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist