Provider Demographics
NPI:1235999384
Name:KENNEDY, DOMINICK (PTA)
Entity Type:Individual
Prefix:
First Name:DOMINICK
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:NICK
Other - Middle Name:
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:804 COLEY DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-2523
Mailing Address - Country:US
Mailing Address - Phone:870-424-2224
Mailing Address - Fax:
Practice Address - Street 1:804 COLEY DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2523
Practice Address - Country:US
Practice Address - Phone:870-424-2224
Practice Address - Fax:870-424-0493
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA4848225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant