MEDICARE: KATRINA KENNEDY PT, DPT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	014570	OH

General Provider Information

NPI Number	:	1407287600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATRINA KENNEDY PT, DPT, ATC

Provider Business Mailing Address
First Line	:	34 W WASHINGTON ST
Second Line	:
City	:	CHAGRIN FALLS
State	:	OH
Zip	:	44022-3026
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	34 W WASHINGTON ST
Second Line	:
City	:	CHAGRIN FALLS
State	:	OH
Zip	:	44022-3026
Country	:	US
Telephone Number	:	440-247-2644
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2013
Last Update Date	:	12/13/2013

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