Healthcare Provider Details

I. General information

NPI: 1043296601
Provider Name (Legal Business Name): DEAN M KENNINGTON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7434 S STATE ST
MIDVALE UT
84047-2014
US

IV. Provider business mailing address

9314 ALVEY LN
SANDY UT
84093-2662
US

V. Phone/Fax

Practice location:
  • Phone: 801-566-4423
  • Fax:
Mailing address:
  • Phone: 801-942-0098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number118629-3501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier20793
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerDESERET MUTUAL
# 2
Identifier107001380101
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerINTRMTN.HEALTHCARE
# 3
IdentifierR79756
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerMEDICAR ADVANTAGE PLANS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: