Healthcare Provider Details

I. General information

NPI: 1063070647
Provider Name (Legal Business Name): GERALD BAIRD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 N STATE ST
OREM UT
84057-2025
US

IV. Provider business mailing address

1420 WESTBURY WAY APT J
LEHI UT
84043-4763
US

V. Phone/Fax

Practice location:
  • Phone: 888-224-8250
  • Fax:
Mailing address:
  • Phone: 385-208-2746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-9052
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12905660-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: