Provider Demographics
NPI:1649503723
Name:GOURLEY, MARY MICHELLE (MFT, LCSW, JD)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:MICHELLE
Last Name:GOURLEY
Suffix:
Gender:F
Credentials:MFT, LCSW, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1390 S 1100 E
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2461
Mailing Address - Country:US
Mailing Address - Phone:801-983-5700
Mailing Address - Fax:801-983-5701
Practice Address - Street 1:1390 S 1100 E
Practice Address - Street 2:SUITE 203
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-2461
Practice Address - Country:US
Practice Address - Phone:801-983-5700
Practice Address - Fax:801-983-5701
Is Sole Proprietor?:No
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13217435011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical