Provider Demographics
NPI:1497990550
Name:BROADBENT, GARY V (LCSW)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:V
Last Name:BROADBENT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2757 E 3600 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-3546
Mailing Address - Country:US
Mailing Address - Phone:801-550-6712
Mailing Address - Fax:
Practice Address - Street 1:5030 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4311
Practice Address - Country:US
Practice Address - Phone:801-550-6712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT113385-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical