Provider Demographics
NPI:1639275498
Name:KENNARD, STACIE DAWN (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:DAWN
Last Name:KENNARD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 DORRENE DR
Mailing Address - Street 2:
Mailing Address - City:WHEELERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45694-1824
Mailing Address - Country:US
Mailing Address - Phone:740-574-2436
Mailing Address - Fax:
Practice Address - Street 1:2125 ROYCE ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-4714
Practice Address - Country:US
Practice Address - Phone:740-876-9232
Practice Address - Fax:740-876-9525
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT-6494225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist