Individual
CHALISE VANDERMYDE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LMT
Contact information
Practice address
370 E SOUTH TEMPLE STE 150, SALT LAKE CITY, UT 84111-1279
(801) 942-3311
Mailing address
PO BOX 711185, SALT LAKE CITY, UT 84171-1185
Taxonomy
Speciality
Code
Description
License number
State
225700000X
Massage Therapist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
11334811-4701
STATE LICENSE
UT
Enumeration date
12/31/2019
Last updated
12/31/2019
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