Provider Demographics
NPI:1972551802
Name:GILMORE, PATRICK D (LCSW)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:D
Last Name:GILMORE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4699 HARRISON BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4368
Mailing Address - Country:US
Mailing Address - Phone:801-479-8286
Mailing Address - Fax:801-479-8247
Practice Address - Street 1:4699 HARRISON BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4368
Practice Address - Country:US
Practice Address - Phone:801-479-8286
Practice Address - Fax:801-479-8247
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT138682-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTR79708Medicare UPIN