Healthcare Provider Details

I. General information

NPI: 1003197658
Provider Name (Legal Business Name): ELIZA RACHELLE GEDGE PH.D., LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2011
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 N FREEDOM BLVD
PROVO UT
84601-1677
US

IV. Provider business mailing address

750 N FREEDOM BLVD
PROVO UT
84601-1677
US

V. Phone/Fax

Practice location:
  • Phone: 801-373-0639
  • Fax: 801-373-0639
Mailing address:
  • Phone: 801-373-0639
  • Fax: 801-373-0639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301014858
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12966150-2501
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number12966150-25801
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: