Waller, Gordon John

Waller, Gordon John is an sole proprietor health care provider with primary practice located at 475 W 260 N , Orem UT 84057-1970. He recently has 2 registered licenses in different health care specialties including Behavioral Health & Social Service Providers / Mental Health, Behavioral Health & Social Service Providers / Behavior Technician. Behavioral Health & Social Service Providers / Behavior Technician is his primary health care specialty. Waller, Gordon John can be contacted via phone (801) 221-9930.

Contact Information

Primary practice address
475 W 260 N Orem UT 84057-1970
Phone: (801) 221-9930
Fax:
Website:
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Health care specialties

SpecialtyCodeLicense #State
Behavioral Health & Social Service Providers / Mental Health 101YM0800X
Behavioral Health & Social Service Providers / Behavior Technician 106S00000X

Profile Details

NPI number 1780121731
LBN Legal business name Waller, Gordon John
Credentials
Entity Individual
Sole proprietor 1 Yes
Enumeration date Jan 30th, 2017
Last updated Jan 12th, 2021 - about 5 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1780121731 NPPES
Utah MEDICAID 1396085718

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