Provider Demographics
NPI:1134377690
Name:KENNEDY, TERRY G (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:G
Last Name:KENNEDY
Suffix:
Gender:M
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 1:1822 W LINCOLN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-5410
Mailing Address - Country:US
Mailing Address - Phone:406-585-4642
Mailing Address - Fax:406-585-2878
Practice Address - Street 1:1822 W LINCOLN ST STE 1
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-5410
Practice Address - Country:US
Practice Address - Phone:406-585-4642
Practice Address - Fax:406-585-2878
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1579225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1579OtherSTATE OF MT PHYSICAL THERAPY LICENSE #1579