Provider Demographics
NPI:1003197658
Name:GEDGE, ELIZA RACHELLE (PHD, LP)
Entity Type:Individual
Prefix:
First Name:ELIZA
Middle Name:RACHELLE
Last Name:GEDGE
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 N FREEDOM BLVD
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1677
Mailing Address - Country:US
Mailing Address - Phone:801-373-0639
Mailing Address - Fax:801-373-0639
Practice Address - Street 1:750 N FREEDOM BLVD
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1677
Practice Address - Country:US
Practice Address - Phone:801-373-0639
Practice Address - Fax:801-373-0639
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014858103TC1900X
UT12966150-25011041C0700X
390200000X
UT12966150-25801103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1883825Medicaid