MEDICARE: CAROLINE KELLOUGH

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	101YM0800X	Mental Health Counselor	10371472-6004	UT

General Provider Information

NPI Number	:	1578108205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLINE KELLOUGH

Provider Business Mailing Address
First Line	:	4465 S 900 E STE 150
Second Line	:
City	:	MILLCREEK
State	:	UT
Zip	:	84124-3944
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4465 S 900 E STE 150
Second Line	:
City	:	MILLCREEK
State	:	UT
Zip	:	84124-3944
Country	:	US
Telephone Number	:	435-248-2089
Fax Number	:

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

Provider Enumeration Date	:	11/18/2019
Last Update Date	:	11/18/2019

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Directions to “ CAROLINE KELLOUGH ” Practice Location

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