Provider Demographics
NPI:1184209546
Name:ERICKSON, GENTREY
Entity Type:Individual
Prefix:
First Name:GENTREY
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12637 S 265 W STE 300
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-5403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12637 S 265 W STE 300
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-5403
Practice Address - Country:US
Practice Address - Phone:801-998-8428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTBACB442682106E00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst