Provider Demographics
NPI:1427698687
Name:FATKIN, KENNETH THOMAS (AMFT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:THOMAS
Last Name:FATKIN
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4626 N 300 W STE 150
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6077
Mailing Address - Country:US
Mailing Address - Phone:801-407-4134
Mailing Address - Fax:801-877-0864
Practice Address - Street 1:393 E RIVERSIDE DR STE 3A
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-7127
Practice Address - Country:US
Practice Address - Phone:435-688-2123
Practice Address - Fax:801-877-0864
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11593493-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist