Healthcare Provider Details

I. General information

NPI: 1275639403
Provider Name (Legal Business Name): BRENDA L KENNEDY P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1951 RIDERWOOD DR
BUTLER AL
36904-3564
US

IV. Provider business mailing address

1951 RIDERWOOD DR
BUTLER AL
36904-3564
US

V. Phone/Fax

Practice location:
  • Phone: 205-459-7655
  • Fax: 205-459-7128
Mailing address:
  • Phone: 205-459-7655
  • Fax: 205-459-7128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberPTH2262
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: