MEDICARE: DR. KREG D GILLMAN PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	352902-2501	UT

General Provider Information

NPI Number	:	1235420365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KREG D GILLMAN PH.D.

Provider Business Mailing Address
First Line	:	730 COVEY LN
Second Line	:
City	:	SANTA CLARA
State	:	UT
Zip	:	84765-5663
Country	:	US
Telephone Number	:	435-652-5185
Fax Number	:

Provider Business Practice Location Address
First Line	:	2107 W SUNSET BLVD
Second Line	:	SUITE 102
City	:	SAINT GEORGE
State	:	UT
Zip	:	84770-7139
Country	:	US
Telephone Number	:	435-862-8273
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2011
Last Update Date	:	04/23/2011

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