Provider Demographics
NPI:1992221733
Name:KENNEDY, CARMEN ROSA (PTA)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:ROSA
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:C
Other - Middle Name:ROSA
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:9057 GARLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SURFSIDE
Mailing Address - State:FL
Mailing Address - Zip Code:33154-3217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9057 GARLAND AVE
Practice Address - Street 2:
Practice Address - City:SURFSIDE
Practice Address - State:FL
Practice Address - Zip Code:33154-3217
Practice Address - Country:US
Practice Address - Phone:786-316-8826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-14
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9747225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty