Provider Demographics
NPI:1700014958
Name:HYDE, GREGORY CLARK (CPCI)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:CLARK
Last Name:HYDE
Suffix:
Gender:M
Credentials:CPCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10151 MAJESTIC CANYON RD
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-4521
Mailing Address - Country:US
Mailing Address - Phone:801-750-8817
Mailing Address - Fax:801-947-0553
Practice Address - Street 1:10151 MAJESTIC CANYON RD
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84092-4521
Practice Address - Country:US
Practice Address - Phone:801-750-8817
Practice Address - Fax:801-947-0553
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-26
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT68360286009101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional