Provider Demographics
NPI:1740566991
Name:HALLSTROM, ANGELA (PT)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:
Last Name:HALLSTROM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8TH AVE & C STREET
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84143-0002
Mailing Address - Country:US
Mailing Address - Phone:801-403-1100
Mailing Address - Fax:
Practice Address - Street 1:8TH AVE & C STREET
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84143-0002
Practice Address - Country:US
Practice Address - Phone:801-403-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT275566-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist