Provider Demographics
NPI:1235344482
Name:KENNEDY, PATRICK B (PTA)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:B
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 ALBERT ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-6505
Mailing Address - Country:US
Mailing Address - Phone:573-335-2086
Mailing Address - Fax:573-335-2398
Practice Address - Street 1:2852 INDEPENDENCE ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5016
Practice Address - Country:US
Practice Address - Phone:573-335-2086
Practice Address - Fax:573-335-2398
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117802225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant