MEDICARE: KEVIN THERIOT PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCSW -0065	AZ

General Provider Information

NPI Number	:	1235229741
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN THERIOT PH.D.

Provider Business Mailing Address
First Line	:	9433 SUNSET RIDGE DR
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84092-2505
Country	:	US
Telephone Number	:	801-432-7049
Fax Number	:

Provider Business Practice Location Address
First Line	:	132 S STATE ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-1506
Country	:	US
Telephone Number	:	801-240-2429
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	02/18/2011

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Directions to “ KEVIN THERIOT PH.D.” Practice Location

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