Provider Demographics
NPI:1790086056
Name:REDDICK, KENNEDY RAY JR
Entity Type:Individual
Prefix:MR
First Name:KENNEDY
Middle Name:RAY
Last Name:REDDICK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 FESCUE CT APT E
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-7866
Mailing Address - Country:US
Mailing Address - Phone:252-933-3666
Mailing Address - Fax:
Practice Address - Street 1:2708 NE 14TH ST APT 5
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062-3564
Practice Address - Country:US
Practice Address - Phone:954-603-7885
Practice Address - Fax:954-342-0273
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist