Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TC1900X | Counseling Psychologist | 6301014858 | MI |
NPI | 1003197658 |
---|---|
Provider Name | Eliza Rachelle Gedge |
First Address | Provo, UT 84601-1677 |
Second Address | Provo, UT 84601-1677 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/09/2011 |
Last Update Date | 03/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1883825 | (05) | MI |