Provider Demographics
NPI:1013642370
Name:KELLEY, STEPHANIE CHURCH (ACMHC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:CHURCH
Last Name:KELLEY
Suffix:
Gender:F
Credentials:ACMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 W SOUTH JORDAN PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-5505
Mailing Address - Country:US
Mailing Address - Phone:385-215-9084
Mailing Address - Fax:
Practice Address - Street 1:1108 W SOUTH JORDAN PKWY STE B
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5505
Practice Address - Country:US
Practice Address - Phone:385-215-9084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT128447186009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT128447186009OtherSTATE LICENSE NUMBER