Provider Demographics
NPI:1164910089
Name:COSTLEY, GERALD LOUIS (LCSW)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:LOUIS
Last Name:COSTLEY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 E 3900 S STE 155
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-1978
Mailing Address - Country:US
Mailing Address - Phone:801-347-0370
Mailing Address - Fax:801-261-3701
Practice Address - Street 1:339 E 3900 S STE 155
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-1978
Practice Address - Country:US
Practice Address - Phone:801-347-0370
Practice Address - Fax:801-261-3701
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2019-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT128158-3501101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor