Provider Demographics
NPI:1871573634
Name:KETTLE, KIMBERLY ANN (LCSW)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANN
Last Name:KETTLE
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 1:8937 S NORTH FORTY RD
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-1726
Mailing Address - Country:US
Mailing Address - Phone:801-944-3408
Mailing Address - Fax:
Practice Address - Street 1:7309 S 180 W
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-1020
Practice Address - Country:US
Practice Address - Phone:801-565-6812
Practice Address - Fax:801-569-9718
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT316386-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT31638635000001Medicare UPIN
UTU006107009851101Medicare UPIN
UTU002695324Medicare UPIN
UTU003942938348Medicare UPIN