Provider Demographics
NPI:1306362975
Name:KENYON, EMILY IRENE (LAT, ATC, CKTP, ITAT)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:IRENE
Last Name:KENYON
Suffix:
Gender:F
Credentials:LAT, ATC, CKTP, ITAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 W 94TH AVE APT 717
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-6233
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12800 MISSISSIPPI PKWY STE A101
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-6901
Practice Address - Country:US
Practice Address - Phone:219-662-5266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002858A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer