Healthcare Provider Details

I. General information

NPI: 1063477321
Provider Name (Legal Business Name): GRETCHEN JAMES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 08/30/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5411 S VINE ST
MURRAY UT
84107-7746
US

IV. Provider business mailing address

450 E 100 S APT 26
SLC UT
84111-1809
US

V. Phone/Fax

Practice location:
  • Phone: 801-209-6610
  • Fax:
Mailing address:
  • Phone: 801-209-6610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5353133-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: