Healthcare Provider Details

I. General information

NPI: 1205958063
Provider Name (Legal Business Name): MARY CATHERINE KENNEDY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 KILBURN STREET THE BODY CENTER
BURLINGTON VT
05401
US

IV. Provider business mailing address

11 KILBURN STREET THE BODY CENTER
BURLINGTON VT
05401
US

V. Phone/Fax

Practice location:
  • Phone: 802-865-9500
  • Fax: 802-865-9559
Mailing address:
  • Phone: 802-865-9500
  • Fax: 802-865-9559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0400003529
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: