Provider Demographics
NPI:1720330228
Name:GERLACH, KRISTINA C (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:C
Last Name:GERLACH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 W 600 N
Mailing Address - Street 2:
Mailing Address - City:TREMONTON
Mailing Address - State:UT
Mailing Address - Zip Code:84337
Mailing Address - Country:US
Mailing Address - Phone:435-257-2168
Mailing Address - Fax:
Practice Address - Street 1:440 W 600 N
Practice Address - Street 2:
Practice Address - City:TREMONTON
Practice Address - State:UT
Practice Address - Zip Code:84337
Practice Address - Country:US
Practice Address - Phone:435-257-2168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7399260-3503104100000X
UT7399260-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker