Provider Demographics
NPI:1346445996
Name:KENNA, KATHLEEN M (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:KENNA
Suffix:
Gender:F
Credentials:PT, DPT
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 1447
Mailing Address - Street 2:
Mailing Address - City:MI WUK VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:95346-1447
Mailing Address - Country:US
Mailing Address - Phone:209-586-5325
Mailing Address - Fax:
Practice Address - Street 1:22511 TWAIN HARTE DR
Practice Address - Street 2:
Practice Address - City:TWAIN HARTE
Practice Address - State:CA
Practice Address - Zip Code:95383-9628
Practice Address - Country:US
Practice Address - Phone:209-586-4689
Practice Address - Fax:209-586-2309
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21909225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist