Healthcare Provider Details

I. General information

NPI: 1356486013
Provider Name (Legal Business Name): GORDON TANNER FOOTE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

672 TEMPLEVIEW DR
BOUNTIFUL UT
84010-1381
US

IV. Provider business mailing address

672 TEMPLEVIEW DR
BOUNTIFUL UT
84010-1381
US

V. Phone/Fax

Practice location:
  • Phone: 469-578-2743
  • Fax:
Mailing address:
  • Phone: 469-578-2743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2996
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16275
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: