Provider Demographics
NPI:1104594308
Name:DEGRACIA, KENEDY (PT, DPT)
Entity type:Individual
Prefix:
First Name:KENEDY
Middle Name:
Last Name:DEGRACIA
Suffix:
Gender:
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KENEDY
Other - Middle Name:
Other - Last Name:FRALEIGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16 MAYBROOK RD STE L
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL HALL
Mailing Address - State:NY
Mailing Address - Zip Code:10916-2741
Mailing Address - Country:US
Mailing Address - Phone:845-636-4344
Mailing Address - Fax:
Practice Address - Street 1:434 OLD POST RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NY
Practice Address - Zip Code:10506-1018
Practice Address - Country:US
Practice Address - Phone:914-234-4445
Practice Address - Fax:914-234-4446
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02039300225100000X
NY054094225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist