Provider Demographics
NPI:1295331494
Name:BENTTI, KENNEDY TAYLOR
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:TAYLOR
Last Name:BENTTI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KENNEDY
Other - Middle Name:TAYLOR
Other - Last Name:GAMANGASSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:555 S 800 E APT 2
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2957
Mailing Address - Country:US
Mailing Address - Phone:832-493-1998
Mailing Address - Fax:
Practice Address - Street 1:2940 N CHURCH ST STE 303
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84040-6617
Practice Address - Country:US
Practice Address - Phone:801-935-4172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician