Provider Demographics
NPI:1326298985
Name:KENNEDY, SARAH MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:MARIE
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 1:6080 SOUTHWEST BLVD
Mailing Address - Street 2:COOPER & BUSH PHYSICAL THERAPY
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76109
Mailing Address - Country:US
Mailing Address - Phone:817-731-9331
Mailing Address - Fax:817-731-9882
Practice Address - Street 1:6080 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76109
Practice Address - Country:US
Practice Address - Phone:817-731-9331
Practice Address - Fax:817-731-9882
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-19
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2067489208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2067489OtherTEXAS LICENSE