Provider Demographics
NPI:1720241466
Name:SKINNER, KEVIN (PHD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:SKINNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:KEVIN
Other - Middle Name:
Other - Last Name:SKINNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:2545 N CANYON RD
Mailing Address - Street 2:#210
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-224-2525
Mailing Address - Fax:
Practice Address - Street 1:2545 N CANYON RD
Practice Address - Street 2:#210
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-5911
Practice Address - Country:US
Practice Address - Phone:801-224-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5014163902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist