Healthcare Provider Details

I. General information

NPI: 1366305898
Provider Name (Legal Business Name): MR. GABRIEL MILES MCKENZIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10434 S 1055 W STE 101
SOUTH JORDAN UT
84095-1521
US

IV. Provider business mailing address

3042 S 2225 E
SALT LAKE CITY UT
84109-2419
US

V. Phone/Fax

Practice location:
  • Phone: 435-565-1305
  • Fax:
Mailing address:
  • Phone: 410-794-6898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13409852-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: