Provider Demographics
NPI:1801140397
Name:GORE, WENDY (SUPPORT STAFF)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:GORE
Suffix:
Gender:F
Credentials:SUPPORT STAFF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2907 E OAKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84109-3611
Mailing Address - Country:US
Mailing Address - Phone:435-216-8678
Mailing Address - Fax:
Practice Address - Street 1:344 E 100 S STE 301
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84111-1727
Practice Address - Country:US
Practice Address - Phone:801-322-4257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)