Provider Demographics
NPI:1235420365
Name:GILLMAN, KREG D (PHD)
Entity Type:Individual
Prefix:DR
First Name:KREG
Middle Name:D
Last Name:GILLMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 COVEY LN
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:UT
Mailing Address - Zip Code:84765-5663
Mailing Address - Country:US
Mailing Address - Phone:435-652-5185
Mailing Address - Fax:
Practice Address - Street 1:2107 W SUNSET BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-7139
Practice Address - Country:US
Practice Address - Phone:435-862-8273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-23
Last Update Date:2011-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT352902-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist