Basic Information
| Provider Information | |||||||||
| NPI: | 1679870604 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | KELSEY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | SSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5965 S 900 E | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841211720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012637100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5965 S 900 E | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841211720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012637100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2011 | ||||||||
| LastUpdateDate: | 02/28/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 289659-3503 | UT | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.