Provider Demographics
NPI:1831695808
Name:STONE, KEOLA THANE (COTA/L)
Entity type:Individual
Prefix:
First Name:KEOLA
Middle Name:THANE
Last Name:STONE
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 W 5350 S
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84405-6743
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5600 S 2700 W
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-1336
Practice Address - Country:US
Practice Address - Phone:208-869-0988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8207091-4204224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty