Healthcare Provider Details

I. General information

NPI: 1194800888
Provider Name (Legal Business Name): GORDON J CHELUNE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

650 KOMAS DR., STE 106A UNIVERSITY OF UTAH
SALT LAKE CITY UT
84108-1225
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2121
  • Fax:
Mailing address:
  • Phone: 801-581-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number6126050-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: