Healthcare Provider Details

I. General information

NPI: 1124982723
Provider Name (Legal Business Name): KENNEDY VAN DAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5558 S 1900 W
TAYLORSVILLE UT
84129-9007
US

IV. Provider business mailing address

6013 S REDWOOD RD
TAYLORSVILLE UT
84123-5220
US

V. Phone/Fax

Practice location:
  • Phone: 801-255-5131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: