Provider Demographics
NPI:1851490510
Name:KENNEDY, AUDREY J (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:J
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 THORNBERRY RD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21550-7000
Mailing Address - Country:US
Mailing Address - Phone:301-387-2919
Mailing Address - Fax:
Practice Address - Street 1:1533 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MD
Practice Address - Zip Code:21550-4338
Practice Address - Country:US
Practice Address - Phone:301-334-1123
Practice Address - Fax:301-334-1129
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18757225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD54736705OtherCAREFIRST BCBS
MD0003OtherFEDERAL BCBS
MD4345383OtherAETNA
WV0200278000Medicaid