Provider Demographics
NPI:1376153122
Name:KENNEDY, DAVID PETER (PTA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:PETER
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 1:100 S 19TH ST APT 809
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68102-1367
Mailing Address - Country:US
Mailing Address - Phone:402-802-5488
Mailing Address - Fax:
Practice Address - Street 1:3110 SCOTT CIR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68112-2604
Practice Address - Country:US
Practice Address - Phone:402-889-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE721225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant