Provider Demographics
NPI:1225652084
Name:KENNELLY, MICHELE (LMT)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:KENNELLY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 VINE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-8922
Mailing Address - Country:US
Mailing Address - Phone:631-987-8822
Mailing Address - Fax:
Practice Address - Street 1:595 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-2646
Practice Address - Country:US
Practice Address - Phone:631-987-8822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-07
Last Update Date:2020-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006622225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist