Healthcare Provider Details

I. General information

NPI: 1407983588
Provider Name (Legal Business Name): STEVEN M GENTRY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 BAMBERGER DR SUITE B
AMERICAN FORK UT
84003-2165
US

IV. Provider business mailing address

4213 WEST SANDALWOOD DRIVE
CEDAR HILLS UT
84062
US

V. Phone/Fax

Practice location:
  • Phone: 801-772-0202
  • Fax: 801-772-0139
Mailing address:
  • Phone: 801-796-7199
  • Fax: 801-772-0139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number276564-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: