Basic Information
Provider Information | |||||||||
NPI: | 1467404202 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GROOM | ||||||||
FirstName: | GARY | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 727 | ||||||||
Address2: |   | ||||||||
City: | BRIGHAM | ||||||||
State: | UT | ||||||||
PostalCode: | 84302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4357340101 | ||||||||
FaxNumber: | 4357340103 | ||||||||
Practice Location | |||||||||
Address1: | 1424 E FOREMASTER DR | ||||||||
Address2: | SUITE 120 | ||||||||
City: | ST GEORGE | ||||||||
State: | UT | ||||||||
PostalCode: | 847906326 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4356568800 | ||||||||
FaxNumber: | 4356271809 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2006 | ||||||||
LastUpdateDate: | 11/15/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1136132501 | UT | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
No ID Information.