Healthcare Provider Details

I. General information

NPI: 1174818769
Provider Name (Legal Business Name): WILLIAM H KENNINGTON OT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 10/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 ADAMS ST
AFTON WY
83110-9621
US

IV. Provider business mailing address

PO BOX 1619
AFTON WY
83110-1619
US

V. Phone/Fax

Practice location:
  • Phone: 307-885-7878
  • Fax:
Mailing address:
  • Phone: 307-885-7878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT-893LP
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: