Healthcare Provider Details

I. General information

NPI: 1467926790
Provider Name (Legal Business Name): TRACEY KENNEDY OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2019
Last Update Date: 01/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3305 S ORANGE AVE
ORLANDO FL
32806-6125
US

IV. Provider business mailing address

13945 ELIOT AVE
ORLANDO FL
32827-7425
US

V. Phone/Fax

Practice location:
  • Phone: 407-852-3347
  • Fax:
Mailing address:
  • Phone: 631-681-0825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT18794
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: