Provider Demographics
NPI:1861599227
Name:COLLEDGE, KENNETH PAUL (PT)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:PAUL
Last Name:COLLEDGE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3578 N. 875 E.
Mailing Address - Street 2:
Mailing Address - City:NORTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414
Mailing Address - Country:US
Mailing Address - Phone:801-668-3500
Mailing Address - Fax:
Practice Address - Street 1:2120 N 400 E
Practice Address - Street 2:
Practice Address - City:NORTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84414-7238
Practice Address - Country:US
Practice Address - Phone:801-668-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT103041-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist