Provider Demographics
NPI:1205363736
Name:KADLECK, PRESTON DAVID (LMFT)
Entity Type:Individual
Prefix:
First Name:PRESTON
Middle Name:DAVID
Last Name:KADLECK
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 W 500 S STE 9
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-2912
Mailing Address - Country:US
Mailing Address - Phone:435-725-6300
Mailing Address - Fax:435-725-6325
Practice Address - Street 1:285 W 800 S
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-3707
Practice Address - Country:US
Practice Address - Phone:435-725-6300
Practice Address - Fax:435-725-6325
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-15
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10366581-3902106H00000X
UT10366581-3904101Y00000X
101Y00000X
UT251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No251S00000XAgenciesCommunity/Behavioral Health