Provider Demographics
NPI:1871683219
Name:GILL, JOHN HAROLD (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HAROLD
Last Name:GILL
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 1:1070 E 300 S
Mailing Address - Street 2:#504
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2554
Mailing Address - Country:US
Mailing Address - Phone:801-364-2616
Mailing Address - Fax:
Practice Address - Street 1:501 CHIPETA WAY
Practice Address - Street 2:#1258
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1222
Practice Address - Country:US
Practice Address - Phone:801-587-3212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT22-106799-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTR34299Medicare UPIN