Provider Demographics
NPI:1356486013
Name:FOOTE, GORDON TANNER
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:TANNER
Last Name:FOOTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:672 TEMPLEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-1381
Mailing Address - Country:US
Mailing Address - Phone:469-578-2743
Mailing Address - Fax:
Practice Address - Street 1:672 TEMPLEVIEW DR
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-1381
Practice Address - Country:US
Practice Address - Phone:469-578-2743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29961041C0700X
TX162751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical