Provider Demographics
NPI:1336151117
Name:GAYLE PHILLIPS, LCSW INC
Entity Type:Organization
Organization Name:GAYLE PHILLIPS, LCSW INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-352-5714
Mailing Address - Street 1:PO BOX 17076
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-0076
Mailing Address - Country:US
Mailing Address - Phone:801-352-5714
Mailing Address - Fax:801-288-0621
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:801-352-5714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT136310-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1720007222OtherINDIVIDUAL NPI
UT000057022Medicare ID - Type Unspecified
UTS14608Medicare UPIN