Provider Demographics
NPI:1528708245
Name:MICHLESEN, SAMUEL (LMT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:MICHLESEN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 W 3500 S STE B
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-3306
Mailing Address - Country:US
Mailing Address - Phone:801-973-1022
Mailing Address - Fax:
Practice Address - Street 1:3800 W 3500 S STE B
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-3306
Practice Address - Country:US
Practice Address - Phone:801-973-1022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12740186-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT12741086-4701OtherUTAH DIVISION OF PROFESSIONAL LICENSING