Provider Demographics
NPI:1811338445
Name:ETHINGTON, KENNETH TILLMAN JR (PTA)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:TILLMAN
Last Name:ETHINGTON
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 S ADAMS ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-3350
Mailing Address - Country:US
Mailing Address - Phone:435-668-2083
Mailing Address - Fax:
Practice Address - Street 1:2707 S ADAMS ST APT 3
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-3350
Practice Address - Country:US
Practice Address - Phone:435-668-2083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5477970-24022251G0304X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic