=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356486013
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GORDON TANNER FOOTE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2007
-----------------------------------------------------
Last Update Date | 07/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 672 TEMPLEVIEW DR
-----------------------------------------------------
City | BOUNTIFUL
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84010-1381
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-578-2743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 672 TEMPLEVIEW DR
-----------------------------------------------------
City | BOUNTIFUL
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84010-1381
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-578-2743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2996
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 16275
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------