Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 104100000X | Social Worker | 9517405-3502 | UT |
Y | 1041C0700X | Clinical Social Worker | 9517405-3501 | UT |
NPI | 1003216458 |
---|---|
Provider Name | Crystal Marie Gregory |
First Address | Enterprise, UT 84725-0563 |
Second Address | Logan, UT 84321-4034 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/09/2014 |
Last Update Date | 09/01/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1003216458 | (05) | UT |