Healthcare Provider Details

I. General information

NPI: 1457781726
Provider Name (Legal Business Name): CAMILLE KENNARD LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2013
Last Update Date: 11/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

537 E COBBLESTONE DR
MIDVALE UT
84047-4602
US

IV. Provider business mailing address

537 E COBBLESTONE DR
MIDVALE UT
84047-4602
US

V. Phone/Fax

Practice location:
  • Phone: 801-397-4900
  • Fax: 801-397-4959
Mailing address:
  • Phone: 801-397-4900
  • Fax: 801-397-4959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number500958-3501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: