Healthcare Provider Details

I. General information

NPI: 1508822321
Provider Name (Legal Business Name): H GRAY OTIS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8817 REDWOOD RD
WEST JORDAN UT
84088-9271
US

IV. Provider business mailing address

3437 BEAR CANYON LN
CEDAR HILLS UT
84062-8014
US

V. Phone/Fax

Practice location:
  • Phone: 801-748-2270
  • Fax: 801-748-2271
Mailing address:
  • Phone: 801-885-8585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5740241-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: