MEDICARE: PAUL JOHN GARDNER MFT

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	57610183902	UT

General Provider Information

NPI Number	:	1558415976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL JOHN GARDNER MFT

Provider Business Mailing Address
First Line	:	5672 OSLO LANE
Second Line	:	PAUL GARDNER
City	:	PARK CITY
State	:	UT
Zip	:	84098
Country	:	US
Telephone Number	:	435-575-7777
Fax Number	:	435-575-7777

Provider Business Practice Location Address
First Line	:	5672 OSLO LANE
Second Line	:	PAUL GARDNER
City	:	PARK CITY
State	:	UT
Zip	:	84098
Country	:	US
Telephone Number	:	435-575-7777
Fax Number	:	435-575-7777

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

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	07/08/2007

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