Basic Information
| Provider Information | |||||||||
| NPI: | 1669836839 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | KYLIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6013 S REDWOOD RD | ||||||||
| Address2: | |||||||||
| City: | TAYLORSVILLE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841235220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012555131 | ||||||||
| FaxNumber: | 8012555131 | ||||||||
| Practice Location | |||||||||
| Address1: | 1558 N 550 W | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840159506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019277078 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2016 | ||||||||
| LastUpdateDate: | 05/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 235Z00000X | 12730379-4104 | UT | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.