Provider Demographics
NPI:1629431788
Name:GILLILAND, RANDY (PHD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:
Last Name:GILLILAND
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 1:412 W 800 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-3728
Mailing Address - Country:US
Mailing Address - Phone:801-235-7246
Mailing Address - Fax:801-226-4098
Practice Address - Street 1:525 W 200 N
Practice Address - Street 2:
Practice Address - City:MONA
Practice Address - State:UT
Practice Address - Zip Code:84648
Practice Address - Country:US
Practice Address - Phone:801-375-4240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9655966-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical