Healthcare Provider Details

I. General information

NPI: 1336723550
Provider Name (Legal Business Name): CORINNE GENTRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2021
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 MEDICAL DR STE D101
BOUNTIFUL UT
84010-8905
US

IV. Provider business mailing address

170 E 1350 N
BOUNTIFUL UT
84010-4577
US

V. Phone/Fax

Practice location:
  • Phone: 801-683-1062
  • Fax:
Mailing address:
  • Phone: 801-413-8192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12877297-3502
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: