Provider Demographics
NPI:1912977505
Name:KENISON, EVAN T (LCSW)
Entity Type:Individual
Prefix:MR
First Name:EVAN
Middle Name:T
Last Name:KENISON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-0751
Mailing Address - Country:US
Mailing Address - Phone:435-850-2547
Mailing Address - Fax:435-843-7438
Practice Address - Street 1:100 S 1000 W
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-4010
Practice Address - Country:US
Practice Address - Phone:435-843-3520
Practice Address - Fax:435-843-3555
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-25
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT30992835011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT832612OtherDESERET MUTUAL
UT942938348OtherCHAMPUS
UT942938348EVKOtherEDUCATORS MUTUAL
UT107029553101OtherINTRMTN. HEALTH CARE