Basic Information
| Provider Information | |||||||||
| NPI: | 1205363736 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KADLECK | ||||||||
| FirstName: | PRESTON | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1140 W 500 S STE 9 | ||||||||
| Address2: | |||||||||
| City: | VERNAL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840782912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357256300 | ||||||||
| FaxNumber: | 4357256325 | ||||||||
| Practice Location | |||||||||
| Address1: | 285 W 800 S | ||||||||
| Address2: | |||||||||
| City: | ROOSEVELT | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840663707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357256300 | ||||||||
| FaxNumber: | 4357256325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2017 | ||||||||
| LastUpdateDate: | 07/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 10366581-3902 | UT | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101Y00000X | 10366581-3904 | UT | N | Behavioral Health & Social Service Providers | Counselor | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 251S00000X | UT | N | Agencies | Community/Behavioral Health |
No ID Information.