Provider Demographics
NPI:1871018333
Name:LEMMON, KAELIE NOEL
Entity type:Individual
Prefix:
First Name:KAELIE
Middle Name:NOEL
Last Name:LEMMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAELIE
Other - Middle Name:NOEL
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1675 N FREEDOM BLVD STE 10B
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6906
Mailing Address - Country:US
Mailing Address - Phone:801-900-6056
Mailing Address - Fax:
Practice Address - Street 1:1675 N FREEDOM BLVD STE 10B
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6906
Practice Address - Country:US
Practice Address - Phone:801-900-6056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-06
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12310278-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist