Provider Demographics
NPI:1982211298
Name:NEVILLE, KENNEDY (OTR/L)
Entity Type:Individual
Prefix:
First Name:KENNEDY
Middle Name:
Last Name:NEVILLE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7816 STANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-3610
Mailing Address - Country:US
Mailing Address - Phone:816-263-0941
Mailing Address - Fax:
Practice Address - Street 1:1177 N WARSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-1800
Practice Address - Country:US
Practice Address - Phone:314-569-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019036581225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO00Medicaid