Provider Demographics
NPI:1952302630
Name:MARIETTA, GAIL (PT)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:
Last Name:MARIETTA
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 1:5151 S 900 E
Mailing Address - Street 2:#100
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-6657
Mailing Address - Country:US
Mailing Address - Phone:801-261-3321
Mailing Address - Fax:801-261-5942
Practice Address - Street 1:5151 S 900 E
Practice Address - Street 2:#100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-6601
Practice Address - Country:US
Practice Address - Phone:801-261-3321
Practice Address - Fax:801-261-5942
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT111716-240225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11171624001001OtherBLUE CROSS BLUE SHIELD
UT5417OtherDMBA
UT870388269BR1OtherEDUCATORS MUTUAL
UT6400386OtherUNITED HEALTHCARE
UT9951986OtherCIGNA
UT68948OtherPEHP
UTCJ9402OtherRAILROAD MEDICARE
UTQM0000060955OtherALTIUS
UTQM0000060955OtherALTIUS
UT6400386OtherUNITED HEALTHCARE