Provider Demographics
NPI:1104665421
Name:ORTIZ, DESTANI AMANDA
Entity type:Individual
Prefix:
First Name:DESTANI
Middle Name:AMANDA
Last Name:ORTIZ
Suffix:
Gender:U
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3588 S 4200 W APT A3
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-3272
Mailing Address - Country:US
Mailing Address - Phone:801-971-9278
Mailing Address - Fax:
Practice Address - Street 1:50 E 9000 S
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2201
Practice Address - Country:US
Practice Address - Phone:801-561-9839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1392825-4003225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist