Provider Demographics
NPI:1760140636
Name:KENDALL, DEREK M (DPT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:M
Last Name:KENDALL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3312 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64507-1956
Mailing Address - Country:US
Mailing Address - Phone:816-752-1622
Mailing Address - Fax:
Practice Address - Street 1:1802 N WOODBINE RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3667
Practice Address - Country:US
Practice Address - Phone:816-232-5113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021046644225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist