Healthcare Provider Details

I. General information

NPI: 1144705716
Provider Name (Legal Business Name): COURTNEY DIANE KENEFICK ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2018
Last Update Date: 09/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 PRESIDENTS CIR
SALT LAKE CITY UT
84112-9049
US

IV. Provider business mailing address

9 VISTA DR
SHREWSBURY MA
01545-2025
US

V. Phone/Fax

Practice location:
  • Phone: 801-585-3861
  • Fax:
Mailing address:
  • Phone: 774-249-9293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number10770591-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: