Provider Demographics
NPI:1912226119
Name:KEENE, CANDICE M (DPT, ATC)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:M
Last Name:KEENE
Suffix:
Gender:F
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 COLLEGE DRIVE
Practice Address - Street 2:UNIVERSITY OF WEST ALABAMA
Practice Address - City:LIVINGSTON
Practice Address - State:AL
Practice Address - Zip Code:35470
Practice Address - Country:US
Practice Address - Phone:205-652-3875
Practice Address - Fax:205-652-3799
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-27
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4272225100000X
ALPTH6403225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist