Provider Demographics
NPI:1154331536
Name:KENYON, CANDACE R (MSPT)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:R
Last Name:KENYON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2013 WELLS BRANCH PKWY
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78728-6900
Mailing Address - Country:US
Mailing Address - Phone:918-781-2536
Mailing Address - Fax:
Practice Address - Street 1:2013 WELLS BRANCH PKWY
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78728
Practice Address - Country:US
Practice Address - Phone:918-781-2536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT3103225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK241416001Medicare ID - Type Unspecified