Provider Demographics
NPI:1326366774
Name:DREYER, KENNETH CHARLES JR (PT)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:CHARLES
Last Name:DREYER
Suffix:JR
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 1:89 CARDINAL RD
Mailing Address - Street 2:
Mailing Address - City:FILLMORE
Mailing Address - State:IN
Mailing Address - Zip Code:46128-9258
Mailing Address - Country:US
Mailing Address - Phone:765-246-6245
Mailing Address - Fax:765-246-6245
Practice Address - Street 1:89 CARDINAL RD
Practice Address - Street 2:
Practice Address - City:FILLMORE
Practice Address - State:IN
Practice Address - Zip Code:46128-9258
Practice Address - Country:US
Practice Address - Phone:317-524-8863
Practice Address - Fax:765-246-4088
Is Sole Proprietor?:No
Enumeration Date:2010-05-10
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006979A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200351820Medicaid
M400062491Medicare PIN