Provider Demographics
NPI:1194468959
Name:TAUILIILI, BRAXTEN (OTR/L)
Entity type:Individual
Prefix:
First Name:BRAXTEN
Middle Name:
Last Name:TAUILIILI
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:382 S 1285 E
Mailing Address - Street 2:
Mailing Address - City:HYRUM
Mailing Address - State:UT
Mailing Address - Zip Code:84319-6707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:765 N 990 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84322-3326
Practice Address - Country:US
Practice Address - Phone:435-890-6152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-19
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12609059-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist