Provider Demographics
NPI:1609485978
Name:VAIL, KELLY MAE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MAE
Last Name:VAIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MAE
Other - Last Name:HODGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1140 W 1130 S BUILDING B
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-2888
Mailing Address - Country:US
Mailing Address - Phone:801-935-4171
Mailing Address - Fax:801-935-4946
Practice Address - Street 1:1140 W 1130 S BUILDING B
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-2888
Practice Address - Country:US
Practice Address - Phone:801-935-4171
Practice Address - Fax:801-935-4946
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician