Provider Demographics
NPI:1669037990
Name:THOMAS, KELLY LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:THOMAS
Suffix:
Gender:M
Credentials:LCSW
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 5290009
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84152-0009
Mailing Address - Country:US
Mailing Address - Phone:801-281-1100
Mailing Address - Fax:801-281-1936
Practice Address - Street 1:716 E 4500 S STE N160
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-3617
Practice Address - Country:US
Practice Address - Phone:801-281-1100
Practice Address - Fax:801-281-1936
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-02
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
UT340474-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator