Provider Demographics
NPI:1912419805
Name:LOTT, BRONSON D (MOT)
Entity Type:Individual
Prefix:
First Name:BRONSON
Middle Name:D
Last Name:LOTT
Suffix:
Gender:M
Credentials:MOT
Other - Prefix:
Other - First Name:BRONSON
Other - Middle Name:D
Other - Last Name:LOTT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MOT
Mailing Address - Street 1:12350 S 800 E
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-9712
Mailing Address - Country:US
Mailing Address - Phone:801-998-8428
Mailing Address - Fax:801-407-1611
Practice Address - Street 1:12350 S 800 E
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9712
Practice Address - Country:US
Practice Address - Phone:801-998-8428
Practice Address - Fax:801-407-1611
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7249603-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist