Healthcare Provider Details

I. General information

NPI: 1831022045
Provider Name (Legal Business Name): KENNEDY WALLS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 NEW TRAILS DR STE 115
SPRING TX
77381-4241
US

IV. Provider business mailing address

8701 NEW TRAILS DR STE 115
SPRING TX
77381-4241
US

V. Phone/Fax

Practice location:
  • Phone: 281-290-4411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-495202
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: