Provider Demographics
NPI:1700831583
Name:HEDIN, KERRY CHARLES (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KERRY
Middle Name:CHARLES
Last Name:HEDIN
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 1:5266 CRUS CORVI RD
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-7733
Mailing Address - Country:US
Mailing Address - Phone:801-969-2957
Mailing Address - Fax:
Practice Address - Street 1:4250 W 5415 S
Practice Address - Street 2:FL 3
Practice Address - City:KEARNS
Practice Address - State:UT
Practice Address - Zip Code:84118-4303
Practice Address - Country:US
Practice Address - Phone:801-969-4181
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT129498-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1294935000001Medicare ID - Type UnspecifiedBCBS INVIDUAL NUMBER
UTQ22493Medicare UPIN