Provider Demographics
NPI:1245977669
Name:MILLARD, GINA ANN (LCSW)
Entity type:Individual
Prefix:MS
First Name:GINA
Middle Name:ANN
Last Name:MILLARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13347 S FREEMAN LN
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-4759
Mailing Address - Country:US
Mailing Address - Phone:801-503-5902
Mailing Address - Fax:
Practice Address - Street 1:2500 S STATE ST
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-3164
Practice Address - Country:US
Practice Address - Phone:385-646-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5623481-35011041C0700X
UT1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical