Provider Demographics
NPI:1689096703
Name:GARRICK, GREGORY E
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:E
Last Name:GARRICK
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 1:375 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:STANSBURY PARK
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9069
Mailing Address - Country:US
Mailing Address - Phone:435-850-2743
Mailing Address - Fax:
Practice Address - Street 1:375 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:STANSBURY PARK
Practice Address - State:UT
Practice Address - Zip Code:84074-9069
Practice Address - Country:US
Practice Address - Phone:435-850-2743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health