Healthcare Provider Details

I. General information

NPI: 1568388007
Provider Name (Legal Business Name): KENNEDY TREGRE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 RIDGEWOOD DR
DAPHNE AL
36526-8116
US

IV. Provider business mailing address

456 RIDGEWOOD DR
DAPHNE AL
36526-8116
US

V. Phone/Fax

Practice location:
  • Phone: 251-404-0698
  • Fax:
Mailing address:
  • Phone: 251-404-0698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-549266
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: