Provider Demographics
NPI:1912327743
Name:GERRITSEN, ANGELA ELIZABETH
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:ELIZABETH
Last Name:GERRITSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:ELIZABETH
Other - Last Name:GERRITSEN HICKOK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1048 W 10250 S
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-4517
Mailing Address - Country:US
Mailing Address - Phone:801-557-8362
Mailing Address - Fax:
Practice Address - Street 1:1048 W 10250 S
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4517
Practice Address - Country:US
Practice Address - Phone:801-557-8362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-19
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT287197-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty