Provider Demographics
NPI:1598398380
Name:WHITE, KEVIN KYLE (CMHC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:KYLE
Last Name:WHITE
Suffix:
Gender:M
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2337 CUSTER AVE
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-1929
Mailing Address - Country:US
Mailing Address - Phone:385-288-9794
Mailing Address - Fax:801-479-9268
Practice Address - Street 1:6000 S 1075 E
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4945
Practice Address - Country:US
Practice Address - Phone:801-479-7035
Practice Address - Fax:801-479-9268
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10086515-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty