Provider Demographics
NPI:1053942466
Name:WOODHOUSE, BRENDA M
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:M
Last Name:WOODHOUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6104 W GINNY CIR
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84128-2530
Mailing Address - Country:US
Mailing Address - Phone:801-824-1563
Mailing Address - Fax:
Practice Address - Street 1:6104 W GINNY CIR
Practice Address - Street 2:
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84128-2530
Practice Address - Country:US
Practice Address - Phone:801-824-1563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
UT10766479-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No133N00000XDietary & Nutritional Service ProvidersNutritionist