MEDICARE: THERESA CATHERINE KENNELLY

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	225X00000X	Occupational Therapist	2472	NE
2	247200000X	Other Technician

General Provider Information

NPI Number	:	1528459690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA CATHERINE KENNELLY

Provider Business Mailing Address
First Line	:	12100 W CENTER RD STE 518
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68144-3960
Country	:	US
Telephone Number	:	402-933-2882
Fax Number	:

Provider Business Practice Location Address
First Line	:	12100 W CENTER RD STE 518
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68144-3960
Country	:	US
Telephone Number	:	402-933-2882
Fax Number	:

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

Provider Enumeration Date	:	02/11/2015
Last Update Date	:	09/22/2020

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