Provider Demographics
NPI:1467404202
Name:GROOM, GARY LEE (PHD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
Last Name:GROOM
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:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM
Mailing Address - State:UT
Mailing Address - Zip Code:84302
Mailing Address - Country:US
Mailing Address - Phone:435-734-0101
Mailing Address - Fax:435-734-0103
Practice Address - Street 1:1424 E FOREMASTER DR
Practice Address - Street 2:SUITE 120
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-6326
Practice Address - Country:US
Practice Address - Phone:435-656-8800
Practice Address - Fax:435-627-1809
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1136132501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist