Provider Demographics
NPI:1184770539
Name:KENNEDY, ALICIA RENE (PT, ATC)
Entity type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:RENE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 UPPER LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:HAWLEY
Mailing Address - State:PA
Mailing Address - Zip Code:18428-4025
Mailing Address - Country:US
Mailing Address - Phone:516-236-1594
Mailing Address - Fax:
Practice Address - Street 1:600 S WYCOMBE AVE
Practice Address - Street 2:
Practice Address - City:YEADON
Practice Address - State:PA
Practice Address - Zip Code:19050-2835
Practice Address - Country:US
Practice Address - Phone:610-626-8065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4142225100000X
MA17515225100000X
PA015897225100000X
OR4541225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist