Provider Demographics
NPI:1003113390
Name:PIERSANTI, KELLY STEVEN (LPC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:STEVEN
Last Name:PIERSANTI
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2646 N 1575 E
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84040-8508
Mailing Address - Country:US
Mailing Address - Phone:801-771-0332
Mailing Address - Fax:
Practice Address - Street 1:44 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MALAD CITY
Practice Address - State:ID
Practice Address - Zip Code:83252-1200
Practice Address - Country:US
Practice Address - Phone:208-766-2389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-22
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-4594101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional