Provider Demographics
NPI:1689052045
Name:KENNEDY, KATHERINE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 BUTTERFLY PL
Mailing Address - Street 2:
Mailing Address - City:TEGA CAY
Mailing Address - State:SC
Mailing Address - Zip Code:29708-0138
Mailing Address - Country:US
Mailing Address - Phone:315-272-7417
Mailing Address - Fax:
Practice Address - Street 1:10516 PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8405
Practice Address - Country:US
Practice Address - Phone:704-541-9080
Practice Address - Fax:704-542-0699
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038839225100000X
SC9986225100000X
NC16014225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist