Healthcare Provider Details

I. General information

NPI: 1861707036
Provider Name (Legal Business Name): GARY EARL BRUNDAGE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2010
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5640 S 3500 W
ROY UT
84067-9158
US

IV. Provider business mailing address

713 HISLOP DR
OGDEN UT
84404-6809
US

V. Phone/Fax

Practice location:
  • Phone: 17-732-8388
  • Fax: 801-773-3025
Mailing address:
  • Phone: 801-814-4376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7435-C
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8666499-3501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: