Provider Demographics
NPI:1790374486
Name:HAUCK, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:HAUCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 E 275 N APT 4
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-6019
Mailing Address - Country:US
Mailing Address - Phone:801-821-8050
Mailing Address - Fax:
Practice Address - Street 1:1392 TURF FARM WAY STE 1-153
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-5587
Practice Address - Country:US
Practice Address - Phone:801-935-5796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTBACB640626106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician