Basic Information
| Provider Information | |||||||||
| NPI: | 1326061854 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLRED | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | JOEL | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 689 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840250689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014517799 | ||||||||
| FaxNumber: | 8014516331 | ||||||||
| Practice Location | |||||||||
| Address1: | 2250 ROBINS DR | ||||||||
| Address2: | |||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840411140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017737060 | ||||||||
| FaxNumber: | 8017746100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 10/24/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 197117-3503 | UT | N | Behavioral Health & Social Service Providers | Social Worker | 164W00000X | 197117-3101 | UT | N | Nursing Service Providers | Licensed Practical Nurse | 1041C0700X | 197117-3501 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.