Provider Demographics
NPI:1184000119
Name:KENNEDY, MARIA BASILIO (PTA)
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:BASILIO
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 S HAWTHORNE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4121
Mailing Address - Country:US
Mailing Address - Phone:336-917-6000
Mailing Address - Fax:336-917-6003
Practice Address - Street 1:1315 S HAWTHORNE RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4121
Practice Address - Country:US
Practice Address - Phone:336-917-6000
Practice Address - Fax:336-917-6003
Is Sole Proprietor?:No
Enumeration Date:2015-07-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA5686225200000X
NC5686225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant