Provider Demographics
NPI:1356767388
Name:MCCAULEY, KEN C (CMHC)
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:C
Last Name:MCCAULEY
Suffix:
Gender:M
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5454 BALSA AVENUE
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84081
Mailing Address - Country:US
Mailing Address - Phone:801-428-9043
Mailing Address - Fax:
Practice Address - Street 1:5454 BALSA AVENUE
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84081
Practice Address - Country:US
Practice Address - Phone:801-428-9043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT357503-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health