Healthcare Provider Details

I. General information

NPI: 1053919969
Provider Name (Legal Business Name): KENNEDY CAILIN DEMBOSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2020
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 E 800 N
OREM UT
84097-4146
US

IV. Provider business mailing address

534 E 800 N
OREM UT
84097-4146
US

V. Phone/Fax

Practice location:
  • Phone: 385-230-7998
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13469304-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: