Provider Demographics
NPI:1720007768
Name:DEHAAN, KENYON MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:KENYON
Middle Name:MICHAEL
Last Name:DEHAAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 LOCKMOOR AVE.
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317
Mailing Address - Country:US
Mailing Address - Phone:319-665-2442
Mailing Address - Fax:
Practice Address - Street 1:1705 S 1ST AVE
Practice Address - Street 2:SUITE C
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-6006
Practice Address - Country:US
Practice Address - Phone:319-337-8818
Practice Address - Fax:319-337-8308
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03042225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist