Provider Demographics
NPI:1861613853
Name:KLEIN, GARY JOEL (LCSW)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:JOEL
Last Name:KLEIN
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 1:1399 S 700 E
Mailing Address - Street 2:SUITE 11B
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2149
Mailing Address - Country:US
Mailing Address - Phone:801-864-7640
Mailing Address - Fax:
Practice Address - Street 1:1399 S 700 E
Practice Address - Street 2:SUITE 11B
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-2149
Practice Address - Country:US
Practice Address - Phone:801-864-7640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5258944 35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1861613853OtherLIFESYNCH
UT1861613853OtherTRIWEST
UT1861613853OtherBLUE CROSS OF UTAH
UT1861613853OtherBLUE CROSS OF UTAH