MEDICARE: KENNETH EUGENE THEVENIN LMFT

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	106H00000X	Marriage & Family Therapist	282730-3902	UT

General Provider Information

NPI Number	:	1497767313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH EUGENE THEVENIN LMFT

Provider Business Mailing Address
First Line	:	50 E NORTH TEMPLE FL 8
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84150-4412
Country	:	US
Telephone Number	:	806-401-4661
Fax Number	:

Provider Business Practice Location Address
First Line	:	50 E NORTH TEMPLE FL 8
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84150-4412
Country	:	US
Telephone Number	:	806-401-4661
Fax Number	:

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

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	08/12/2019

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