Provider Demographics
NPI:1972078251
Name:PETERSON, KYLE (LCMHC)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N MAIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84721-6158
Mailing Address - Country:US
Mailing Address - Phone:435-250-4367
Mailing Address - Fax:
Practice Address - Street 1:415 N MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84721-6158
Practice Address - Country:US
Practice Address - Phone:701-852-3328
Practice Address - Fax:651-925-0057
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-12
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11390362-6004101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health