Provider Demographics
NPI:1740242577
Name:ALLEN, GERALD ELDRIDGE KAWIKA (MS)
Entity type:Individual
Prefix:MR
First Name:GERALD
Middle Name:ELDRIDGE KAWIKA
Last Name:ALLEN
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 CEDAR CREST DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-2923
Mailing Address - Country:US
Mailing Address - Phone:801-733-5190
Mailing Address - Fax:801-944-1698
Practice Address - Street 1:8184 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-6477
Practice Address - Country:US
Practice Address - Phone:801-944-1666
Practice Address - Fax:801-944-1698
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5055381-6009101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000000000000Medicaid