Provider Demographics
NPI:1699105338
Name:TOTAL THETA WELLNESS
Entity type:Organization
Organization Name:TOTAL THETA WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHWICK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:801-943-3373
Mailing Address - Street 1:8789 S HIGHLAND DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-1600
Mailing Address - Country:US
Mailing Address - Phone:801-943-3373
Mailing Address - Fax:801-943-0599
Practice Address - Street 1:8789 S HIGHLAND DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-1600
Practice Address - Country:US
Practice Address - Phone:801-943-3373
Practice Address - Fax:801-943-0599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-15
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT200020-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty