Provider Demographics
NPI:1578031282
Name:KENNEMER, JUSTIN DWAYNE (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:DWAYNE
Last Name:KENNEMER
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 1:331 S BOLDEN HILL RD
Mailing Address - Street 2:
Mailing Address - City:GREENBRIER
Mailing Address - State:AR
Mailing Address - Zip Code:72058-9024
Mailing Address - Country:US
Mailing Address - Phone:817-688-5865
Mailing Address - Fax:
Practice Address - Street 1:385 HIGHWAY 65 N
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-3506
Practice Address - Country:US
Practice Address - Phone:501-697-9881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR2937225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics