Provider Demographics
NPI:1407697816
Name:PAXMAN-BLACK, KENDALL KRISTANNE (MSW, CSW)
Entity type:Individual
Prefix:MS
First Name:KENDALL
Middle Name:KRISTANNE
Last Name:PAXMAN-BLACK
Suffix:
Gender:F
Credentials:MSW, CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3872
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3872
Mailing Address - Country:US
Mailing Address - Phone:801-521-4227
Mailing Address - Fax:801-359-0777
Practice Address - Street 1:352 S DENVER ST STE 350
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-3059
Practice Address - Country:US
Practice Address - Phone:801-521-4227
Practice Address - Fax:801-359-0777
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
10697151-3502101YA0400X, 101YM0800X
UT10697151-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health