Provider Demographics
NPI:1518734029
Name:KENNEDY, KRISTA MARIE (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:KRISTA
Middle Name:MARIE
Last Name:KENNEDY
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 1:315 ARLINGTON GLEN CT
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-3973
Mailing Address - Country:US
Mailing Address - Phone:314-941-4577
Mailing Address - Fax:
Practice Address - Street 1:3510 WOODSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63114-4203
Practice Address - Country:US
Practice Address - Phone:314-493-6430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004024381225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist