Provider Demographics
NPI:1376637223
Name:WILLEFORD, KENNETH SEAN (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:SEAN
Last Name:WILLEFORD
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:TCU BOX 297730
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76129
Mailing Address - Country:US
Mailing Address - Phone:817-257-6737
Mailing Address - Fax:817-257-7702
Practice Address - Street 1:3005 STADIUM DRIVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109
Practice Address - Country:US
Practice Address - Phone:817-257-6737
Practice Address - Fax:817-257-7702
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT34652255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer