Basic Information
| Provider Information | |||||||||
| NPI: | 1639358997 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | ALLISON | ||||||||
| MiddleName: | VARGAS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VARGAS | ||||||||
| OtherFirstName: | ALLISON | ||||||||
| OtherMiddleName: | REBECCA | ||||||||
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| OtherCredential: | OTR/L | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1377 MOTOR PKWY STE 307 | ||||||||
| Address2: | |||||||||
| City: | ISLANDIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117495258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315805200 | ||||||||
| FaxNumber: | 6315805222 | ||||||||
| Practice Location | |||||||||
| Address1: | 1157 FIRST COLONIAL RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234542432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574810052 | ||||||||
| FaxNumber: | 7574811099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2007 | ||||||||
| LastUpdateDate: | 06/03/2019 | ||||||||
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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 | 225XP0200X | OT 12943 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 225X00000X | OT 12943 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 0119006447 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 892541100 | 05 | FL | MEDICAID | Z152T | 01 | FL | BCBS | OTHER |