Provider Demographics
NPI:1225197759
Name:GAEDE, RUSSELL CLIFFORD (PSYD, LPC)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:CLIFFORD
Last Name:GAEDE
Suffix:
Gender:M
Credentials:PSYD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1001
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-7001
Mailing Address - Country:US
Mailing Address - Phone:801-623-4770
Mailing Address - Fax:801-623-4771
Practice Address - Street 1:1835 N 1120 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1180
Practice Address - Country:US
Practice Address - Phone:801-623-4770
Practice Address - Fax:801-623-4771
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT268792-6004101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor