Basic Information
| Provider Information | |||||||||
| NPI: | 1518282508 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GULLBERG | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MFT, RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 FOOTHILL DR | ||||||||
| Address2: | OP116 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015821565 | ||||||||
| FaxNumber: | 8015842544 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 FOOTHILL DR | ||||||||
| Address2: | OP116 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015821565 | ||||||||
| FaxNumber: | 8015842544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2010 | ||||||||
| LastUpdateDate: | 04/01/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 19103 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 106H00000X | 01 | CA | MARRIAGE FAMILY THERAPIST | OTHER |