Provider Demographics
NPI:1134795297
Name:DERN, KYLE (MA, LMFT, BCN)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:DERN
Suffix:
Gender:M
Credentials:MA, LMFT, BCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:638 E 200 S
Mailing Address - Street 2:
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532-2747
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 E CENTER ST STE 7
Practice Address - Street 2:
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532-2473
Practice Address - Country:US
Practice Address - Phone:970-317-4290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-31
Last Update Date:2021-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10844622-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist