Provider Demographics
NPI:1720007222
Name:PHILLIPS, GAYLE (LCSW)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 E 4500 S
Mailing Address - Street 2:SUITE #302
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3002
Mailing Address - Country:US
Mailing Address - Phone:801-288-0617
Mailing Address - Fax:
Practice Address - Street 1:860 E 4500 S
Practice Address - Street 2:SUITE #302
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-3002
Practice Address - Country:US
Practice Address - Phone:801-288-0617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT136310-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTS14608Medicare UPIN
UT000057022Medicare ID - Type Unspecified