Provider Demographics
NPI:1457572554
Name:KENNEDY-LEARY, LISA MARIE (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:KENNEDY-LEARY
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 1:1118 SE TEAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2303
Mailing Address - Country:US
Mailing Address - Phone:541-382-5515
Mailing Address - Fax:
Practice Address - Street 1:1441 SW CHANDLER AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3221
Practice Address - Country:US
Practice Address - Phone:541-312-2252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2477225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR840574002OtherBLUE CROSS PIN
ORJ6507-02OtherPACIFIC SOURCE PIN
ORJ6507-02OtherPACIFIC SOURCE PIN