Provider Demographics
NPI:1558415976
Name:GARDNER, PAUL JOHN (MFT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:JOHN
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5672 OSLO LANE
Mailing Address - Street 2:PAUL GARDNER
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098
Mailing Address - Country:US
Mailing Address - Phone:435-575-7777
Mailing Address - Fax:435-575-7777
Practice Address - Street 1:5672 OSLO LANE
Practice Address - Street 2:PAUL GARDNER
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098
Practice Address - Country:US
Practice Address - Phone:435-575-7777
Practice Address - Fax:435-575-7777
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT57610183902103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist