Basic Information
| Provider Information | |||||||||
| NPI: | 1003216458 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREGORY | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | L.C.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 290 N 100 E | ||||||||
| Address2: | |||||||||
| City: | LEHI | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840431804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017033941 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9361 S 300 E | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840702902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8018265000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2014 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 9517405-3501 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1003216458 | 05 | UT | MEDICAID |