Provider Demographics
NPI:1891831921
Name:KENNEMORE, KIMBERLY N (OT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:N
Last Name:KENNEMORE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:R
Other - Last Name:NOWICKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 WINCHESTER PL
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-1518
Mailing Address - Country:US
Mailing Address - Phone:864-576-7188
Mailing Address - Fax:864-576-8909
Practice Address - Street 1:2400 WINCHESTER PL
Practice Address - Street 2:SUITE 102
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-1518
Practice Address - Country:US
Practice Address - Phone:864-576-7188
Practice Address - Fax:864-576-8909
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3049225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1619Medicaid