Provider Demographics
NPI:1336233097
Name:SAZAMA, GARY P (PHD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:P
Last Name:SAZAMA
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 1:150 E 200 N
Mailing Address - Street 2:SUITE: O
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-4036
Mailing Address - Country:US
Mailing Address - Phone:435-752-8010
Mailing Address - Fax:
Practice Address - Street 1:150 E 200 N
Practice Address - Street 2:SUITE: O
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4036
Practice Address - Country:US
Practice Address - Phone:435-752-8010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT112064-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical