Provider Demographics
NPI:1700155561
Name:GARDNER, GORDON PAUL
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:PAUL
Last Name:GARDNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7052 LOCH NESS AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84128-2323
Mailing Address - Country:US
Mailing Address - Phone:801-718-0158
Mailing Address - Fax:
Practice Address - Street 1:650 E 4500 S STE 300
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-4502
Practice Address - Country:US
Practice Address - Phone:801-261-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-23
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
UT1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)