Provider Demographics
NPI:1831636380
Name:BREITWEISER, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:BREITWEISER
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 1:1435 VILLAGE DR DEPT 2805
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84408-5150
Mailing Address - Country:US
Mailing Address - Phone:801-626-7656
Mailing Address - Fax:
Practice Address - Street 1:1435 VILLAGE DR DEPT 2805
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84408-5150
Practice Address - Country:US
Practice Address - Phone:801-626-7656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer