Provider Demographics
NPI:1477161735
Name:MCCLEERY VIXAYSACK, CAROLINE (PT, DPT, ATC)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:MCCLEERY VIXAYSACK
Suffix:
Gender:
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:CAROLINE
Other - Middle Name:
Other - Last Name:MCCLEERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:PO BOX 25537
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6272 S HIGHLAND DR STE 203
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84121-2126
Practice Address - Country:US
Practice Address - Phone:801-871-6350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11881200-48102255A2300X
UT11881200-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer