Provider Demographics
NPI:1780331207
Name:HENNEBERGER, KENNEDI (PT, DPT)
Entity type:Individual
Prefix:
First Name:KENNEDI
Middle Name:
Last Name:HENNEBERGER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E FM 2410 RD STE D
Mailing Address - Street 2:
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-6898
Mailing Address - Country:US
Mailing Address - Phone:254-394-2710
Mailing Address - Fax:254-307-9700
Practice Address - Street 1:1200 E FM 2410 RD STE D
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-6898
Practice Address - Country:US
Practice Address - Phone:254-394-2710
Practice Address - Fax:254-307-9700
Is Sole Proprietor?:No
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1356870225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist