Provider Demographics
NPI:1366103525
Name:FORD, KYLEE (LCSW)
Entity type:Individual
Prefix:
First Name:KYLEE
Middle Name:
Last Name:FORD
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 1:32 W 200 S # 233
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84101-1603
Mailing Address - Country:US
Mailing Address - Phone:435-200-3458
Mailing Address - Fax:
Practice Address - Street 1:501 CHIPTA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108
Practice Address - Country:US
Practice Address - Phone:435-200-3458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-09
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10895067-3501104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10895067-3501OtherNASW