Healthcare Provider Details

I. General information

NPI: 1962479121
Provider Name (Legal Business Name): CAROL GAGE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1399 S 700 E SUITE 15
SALT LAKE CITY UT
84105-2149
US

IV. Provider business mailing address

1399 S 700 E SUITE 15
SALT LAKE CITY UT
84105-2149
US

V. Phone/Fax

Practice location:
  • Phone: 801-487-2357
  • Fax: 801-487-0963
Mailing address:
  • Phone: 801-487-2357
  • Fax: 801-487-0963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number80-109840-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: