Provider Demographics
NPI:1083762108
Name:KENNEDY, MELISSA FOURNIER (PT, OCS)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:FOURNIER
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PT, OCS
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:FOURNIER
Other - Last Name:FOURNIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT, OCS
Mailing Address - Street 1:143 LONGWATER DR
Mailing Address - Street 2:
Mailing Address - City:NORWELL
Mailing Address - State:MA
Mailing Address - Zip Code:02061-1683
Mailing Address - Country:US
Mailing Address - Phone:781-878-5200
Mailing Address - Fax:
Practice Address - Street 1:143 LONGWATER DR
Practice Address - Street 2:
Practice Address - City:NORWELL
Practice Address - State:MA
Practice Address - Zip Code:02061-1683
Practice Address - Country:US
Practice Address - Phone:781-878-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18230225100000X
CT007666225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000656901Medicare PIN