Provider Demographics
NPI:1730107269
Name:KENNEDY, STEVEN THOMAS (DC)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:THOMAS
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11515 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2127
Mailing Address - Country:US
Mailing Address - Phone:414-257-2575
Mailing Address - Fax:414-257-1778
Practice Address - Street 1:11515 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-2127
Practice Address - Country:US
Practice Address - Phone:414-257-2575
Practice Address - Fax:414-257-1778
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2501111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38845500Medicaid
WI38845500Medicaid
WI000175520Medicare ID - Type Unspecified