Basic Information
| Provider Information | |||||||||
| NPI: | 1467598532 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | DEBORAH | ||||||||
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| Credential: | OTRL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5711 29TH AVENUE DR E | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342086556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417223582 | ||||||||
| FaxNumber: | 9417298322 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 10TH AVE W | ||||||||
| Address2: | |||||||||
| City: | PALMETTO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342215032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417223582 | ||||||||
| FaxNumber: | 9417398322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 01/19/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT966 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 880237800 | 05 | FL | MEDICAID | 8121281 00 | 05 | FL | MEDICAID |