Healthcare Provider Details

I. General information

NPI: 1750262093
Provider Name (Legal Business Name): MICAELA KENNEDY PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2025
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 WING DR STE 203
CEDAR KNOLLS NJ
07927-1024
US

IV. Provider business mailing address

106 BRUNSWICK RD
CEDAR GROVE NJ
07009-1404
US

V. Phone/Fax

Practice location:
  • Phone: 862-260-9656
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number40QA02372500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: