Provider Demographics
NPI:1285221317
Name:MAMMEN, KYLE PATTERSON
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:PATTERSON
Last Name:MAMMEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:372 N 650 W
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-5620
Mailing Address - Country:US
Mailing Address - Phone:801-499-0520
Mailing Address - Fax:
Practice Address - Street 1:372 N 650 W
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-5620
Practice Address - Country:US
Practice Address - Phone:801-499-0520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8720265-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional