Provider Demographics
NPI:1295857266
Name:GOUDIE, KYLE HANSEN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:HANSEN
Last Name:GOUDIE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11451 S 700 E
Mailing Address - Street 2:SUITE E
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8204
Mailing Address - Country:US
Mailing Address - Phone:801-330-6324
Mailing Address - Fax:801-330-6324
Practice Address - Street 1:11451 S 700 E
Practice Address - Street 2:SUITE E
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8204
Practice Address - Country:US
Practice Address - Phone:801-330-6324
Practice Address - Fax:801-330-6324
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6370645-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical