Provider Demographics
NPI:1235229741
Name:THERIOT, KEVIN (PHD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:THERIOT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9433 SUNSET RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-2505
Mailing Address - Country:US
Mailing Address - Phone:801-432-7049
Mailing Address - Fax:
Practice Address - Street 1:132 S STATE ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1506
Practice Address - Country:US
Practice Address - Phone:801-240-2429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW -00651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical