Provider Demographics
NPI:1740650480
Name:TANNER, MELINDA (OTR)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:
Other - Last Name:TANNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:50 N. MEDICAL DRIVE SOM 1R73
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132
Mailing Address - Country:US
Mailing Address - Phone:801-213-7312
Mailing Address - Fax:
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-581-2733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9233483-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist