Provider Demographics
NPI:1235264789
Name:KENNEY, ROBERT A III (PT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:KENNEY
Suffix:III
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:PO BOX 5477
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-5477
Mailing Address - Country:US
Mailing Address - Phone:318-681-5633
Mailing Address - Fax:318-681-5685
Practice Address - Street 1:8835 LINE AVE STE 100
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-6731
Practice Address - Country:US
Practice Address - Phone:318-681-5643
Practice Address - Fax:318-681-5685
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4689225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2140116Medicaid
LA3C271DS30Medicare PIN
LA2140116Medicaid