Provider Demographics
NPI:1003950304
Name:KENNEDY, MISTY MILAM (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:MILAM
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 EVELYN RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-3046
Mailing Address - Country:US
Mailing Address - Phone:870-739-0040
Mailing Address - Fax:
Practice Address - Street 1:133 MILITARY RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-1755
Practice Address - Country:US
Practice Address - Phone:870-739-5111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1443225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist