Healthcare Provider Details

I. General information

NPI: 1770058802
Provider Name (Legal Business Name): ANGELA MARIE GEHRKE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2018
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9138 S 6200 W
PAYSON UT
84651-9772
US

IV. Provider business mailing address

9138 S 6200 W
PAYSON UT
84651-9772
US

V. Phone/Fax

Practice location:
  • Phone: 801-558-6985
  • Fax:
Mailing address:
  • Phone: 801-558-6985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11912618-3502
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11912618-3502
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: