Provider Demographics
NPI:1336181833
Name:REARDON, KERRY (PT)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:REARDON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2613 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-5628
Mailing Address - Country:US
Mailing Address - Phone:985-626-3286
Mailing Address - Fax:
Practice Address - Street 1:1311 GAUSE BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-3015
Practice Address - Country:US
Practice Address - Phone:985-649-6577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA01466R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4B940BD21OtherMEDICARE ID
LA4B940BD21Medicare UPIN
LA4B940CS21Medicare UPIN
LA4B940CS21Medicare PIN
LA4B940BD21OtherMEDICARE ID
LA4B940BD21Medicare PIN