Provider Demographics
NPI:1194352088
Name:CHRISTENSEN, KEVIN JOSEPH
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOSEPH
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1346 W 8580 S
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-8299
Mailing Address - Country:US
Mailing Address - Phone:801-755-1934
Mailing Address - Fax:
Practice Address - Street 1:5121 S COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5701
Practice Address - Country:US
Practice Address - Phone:801-755-1934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8738307-4201225XE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental Modification