Provider Demographics
NPI:1013165802
Name:HOLBROOK, GARRY RICHARD SR (LCSW)
Entity type:Individual
Prefix:
First Name:GARRY
Middle Name:RICHARD
Last Name:HOLBROOK
Suffix:SR
Gender:M
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:PO BOX 63
Mailing Address - Street 2:
Mailing Address - City:PANGUITCH
Mailing Address - State:UT
Mailing Address - Zip Code:84759-0063
Mailing Address - Country:US
Mailing Address - Phone:435-676-3020
Mailing Address - Fax:435-676-8832
Practice Address - Street 1:609 NORTH MAIN
Practice Address - Street 2:#3
Practice Address - City:PANGUITCH
Practice Address - State:UT
Practice Address - Zip Code:84759
Practice Address - Country:US
Practice Address - Phone:435-676-3020
Practice Address - Fax:435-676-8832
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health