Provider Demographics
NPI:1437790755
Name:KENNELLY, KATHRYN (OTR/L)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:KENNELLY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 W ARROWHEAD CLUBHOUSE DR APT 3081
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8890
Mailing Address - Country:US
Mailing Address - Phone:623-640-6165
Mailing Address - Fax:
Practice Address - Street 1:1505 N ALMA SCHOOL RD STE 2
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-2900
Practice Address - Country:US
Practice Address - Phone:623-640-6165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-007904225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist