Provider Demographics
NPI:1023285863
Name:FENNELL, ROBERT (ATC, MS)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:FENNELL
Suffix:
Gender:M
Credentials:ATC, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 VALPARAISO AVE
Mailing Address - Street 2:
Mailing Address - City:ATHERTON
Mailing Address - State:CA
Mailing Address - Zip Code:94027-4402
Mailing Address - Country:US
Mailing Address - Phone:650-473-4035
Mailing Address - Fax:
Practice Address - Street 1:150 VALPARAISO AVE
Practice Address - Street 2:
Practice Address - City:ATHERTON
Practice Address - State:CA
Practice Address - Zip Code:94027-4402
Practice Address - Country:US
Practice Address - Phone:650-473-4035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0026012255A2300X
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer