Provider Demographics
NPI:1326208307
Name:MCPHETERS, JUSTIN KADE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:KADE
Last Name:MCPHETERS
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 1:1311 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-1310
Mailing Address - Country:US
Mailing Address - Phone:801-520-0868
Mailing Address - Fax:
Practice Address - Street 1:1311 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-1310
Practice Address - Country:US
Practice Address - Phone:801-919-4749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-12
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166000733106H00000X
UT4783660-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist