Provider Demographics
NPI:1881651115
Name:ELDER, AUSTIN KYLE
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:KYLE
Last Name:ELDER
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:PO BOX 867
Mailing Address - Street 2:105 WEST 100 NORTH
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501
Mailing Address - Country:US
Mailing Address - Phone:435-637-7200
Mailing Address - Fax:435-637-2377
Practice Address - Street 1:575 EAST 100 SOUTH
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501
Practice Address - Country:US
Practice Address - Phone:435-637-2358
Practice Address - Fax:435-637-9141
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1176492501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q16915Medicare UPIN