Healthcare Provider Details

I. General information

NPI: 1972551802
Provider Name (Legal Business Name): PATRICK D GILMORE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 11/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4699 HARRISON BLVD SUITE 300
OGDEN UT
84405-4368
US

IV. Provider business mailing address

4699 HARRISON BLVD SUITE 300
OGDEN UT
84403-4368
US

V. Phone/Fax

Practice location:
  • Phone: 801-479-8286
  • Fax: 801-479-8247
Mailing address:
  • Phone: 801-479-8286
  • Fax: 801-479-8247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number138682-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: