Healthcare Provider Details

I. General information

NPI: 1205363736
Provider Name (Legal Business Name): PRESTON DAVID KADLECK LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2017
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 W 800 S
ROOSEVELT UT
84066-3707
US

IV. Provider business mailing address

1140 W 500 S STE 9
VERNAL UT
84078-2912
US

V. Phone/Fax

Practice location:
  • Phone: 435-725-6300
  • Fax: 435-725-6325
Mailing address:
  • Phone: 435-725-6300
  • Fax: 435-725-6325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number10366581-3904
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number10366581-3902
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: