Provider Demographics
NPI:1932707635
Name:BERAN-MARYOTT, GILLIAN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:GILLIAN
Middle Name:
Last Name:BERAN-MARYOTT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 S MAIN ST APT 4309
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-3078
Mailing Address - Country:US
Mailing Address - Phone:503-896-6080
Mailing Address - Fax:
Practice Address - Street 1:165 S 1000 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1402
Practice Address - Country:US
Practice Address - Phone:801-322-5521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11819269-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist