Provider Demographics
NPI:1669565131
Name:HOLDEN, THERESA A (PT)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:HOLDEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 S MELBOURNE STREET
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84106
Mailing Address - Country:US
Mailing Address - Phone:801-467-4637
Mailing Address - Fax:
Practice Address - Street 1:44 MEDICAL DRIVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84113
Practice Address - Country:US
Practice Address - Phone:801-584-8521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT110220-24012251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT999000021002Medicaid
UT1699878942OtherUDOH CFHS