Basic Information
| Provider Information | |||||||||
| NPI: | 1043587751 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MS, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34 BIRCHWOOD AVE APT 5 | ||||||||
| Address2: | |||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142242132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165158712 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4225 GENESEE ST | ||||||||
| Address2: | |||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142251994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162043200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2011 | ||||||||
| LastUpdateDate: | 08/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 002084-1 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.