Provider Demographics
NPI:1861707036
Name:BRUNDAGE, GARY EARL
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:EARL
Last Name:BRUNDAGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 HISLOP DR
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-6809
Mailing Address - Country:US
Mailing Address - Phone:801-814-4376
Mailing Address - Fax:
Practice Address - Street 1:5640 S 3500 W
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-9158
Practice Address - Country:US
Practice Address - Phone:017-732-8388
Practice Address - Fax:801-773-3025
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7435-C1041C0700X
UT8666499-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical