Provider Demographics
NPI:1336407568
Name:KERN, STEPHEN (LSCSW)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:KERN
Suffix:
Gender:M
Credentials:LSCSW
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 353
Mailing Address - Street 2:
Mailing Address - City:LOA
Mailing Address - State:UT
Mailing Address - Zip Code:84747-0353
Mailing Address - Country:US
Mailing Address - Phone:435-836-2272
Mailing Address - Fax:435-836-2274
Practice Address - Street 1:1764 WEST ASPEN LANE
Practice Address - Street 2:
Practice Address - City:LOA
Practice Address - State:UT
Practice Address - Zip Code:84747
Practice Address - Country:US
Practice Address - Phone:435-836-2272
Practice Address - Fax:435-836-2274
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS41741041C0700X
UT6178738-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200966490AMedicaid