Healthcare Provider Details

I. General information

NPI: 1184209546
Provider Name (Legal Business Name): GENTREY ERICKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12637 S 265 W STE 300
DRAPER UT
84020-5403
US

IV. Provider business mailing address

12637 S 265 W STE 300
DRAPER UT
84020-5403
US

V. Phone/Fax

Practice location:
  • Phone: 801-998-8428
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License NumberBACB442682
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: