Healthcare Provider Details

I. General information

NPI: 1629992789
Provider Name (Legal Business Name): KENNEDI PHILLIPS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 LEGENDS PARKWAY 157
EUREKA MO
63025
US

IV. Provider business mailing address

13935 REFLECTION CT APT 714
BALLWIN MO
63021-8044
US

V. Phone/Fax

Practice location:
  • Phone: 636-252-4464
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number2026036188
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: