Healthcare Provider Details

I. General information

NPI: 1700155561
Provider Name (Legal Business Name): GORDON PAUL GARDNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2011
Last Update Date: 02/03/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 E 4500 S STE 300
MURRAY UT
84107-4502
US

IV. Provider business mailing address

7052 LOCH NESS AVE
SALT LAKE CITY UT
84128-2323
US

V. Phone/Fax

Practice location:
  • Phone: 801-261-3500
  • Fax:
Mailing address:
  • Phone: 801-718-0158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: