Provider Demographics
NPI:1659486256
Name:WALDO, JULIE L (MPT, OCS, CMPT)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:L
Last Name:WALDO
Suffix:
Gender:F
Credentials:MPT, OCS, CMPT
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:LYNN
Other - Last Name:THIESZEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT, OCS, CMPT
Mailing Address - Street 1:188 E ENSIGN VISTA DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-2260
Mailing Address - Country:US
Mailing Address - Phone:801-769-6778
Mailing Address - Fax:385-202-7615
Practice Address - Street 1:150 S 600 E STE 3B
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1961
Practice Address - Country:US
Practice Address - Phone:801-769-6778
Practice Address - Fax:385-202-7615
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2251X0800X
UT344119-2401174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000077347Medicare PIN