Provider Demographics
NPI:1649046301
Name:CORNISH, TERAH KAY (LMT)
Entity type:Individual
Prefix:MRS
First Name:TERAH
Middle Name:KAY
Last Name:CORNISH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:TERAH
Other - Middle Name:KAY
Other - Last Name:JAMISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2037 W SPRUCE CREEK LN # B
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-2409
Mailing Address - Country:US
Mailing Address - Phone:385-479-0433
Mailing Address - Fax:
Practice Address - Street 1:4568 S HIGHLAND DR STE 150
Practice Address - Street 2:
Practice Address - City:MILLCREEK
Practice Address - State:UT
Practice Address - Zip Code:84117-4242
Practice Address - Country:US
Practice Address - Phone:385-479-0433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9657703-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist