Provider Demographics
NPI:1982164554
Name:KENNEDY, SUZANNE (LMT)
Entity Type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 MONROE ST STE 4
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-5176
Mailing Address - Country:US
Mailing Address - Phone:541-914-0512
Mailing Address - Fax:
Practice Address - Street 1:825 MONROE ST STE 4
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-5176
Practice Address - Country:US
Practice Address - Phone:541-914-0512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24871225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR24871Medicaid