Provider Demographics
NPI:1508075334
Name:CORCORAN, KENNETH JOSEPH (PT, DPT, SCS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JOSEPH
Last Name:CORCORAN
Suffix:
Gender:M
Credentials:PT, DPT, SCS
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 12512
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28220-2512
Mailing Address - Country:US
Mailing Address - Phone:716-830-4866
Mailing Address - Fax:
Practice Address - Street 1:2826 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1386
Practice Address - Country:US
Practice Address - Phone:716-830-4866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029027-12251S0007X
NJ40QA013684002251S0007X
NC183232251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA01368400OtherLICENSE NUMBER
NY029027-1OtherLICENSE NUMBER
NC18323OtherLICENSE NUMBER