Provider Demographics
NPI:1508316621
Name:KENNEDY, JUSTIN W (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:W
Last Name:KENNEDY
Suffix:
Gender:M
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 1:8640 REVERE CT
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31820-4223
Mailing Address - Country:US
Mailing Address - Phone:706-577-4591
Mailing Address - Fax:
Practice Address - Street 1:8640 REVERE CT
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:GA
Practice Address - Zip Code:31820-4223
Practice Address - Country:US
Practice Address - Phone:706-577-4591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4032225X00000X
GAOT006206225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist