=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194532523
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GABRIELLE KENNEDY OTD, OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2024
-----------------------------------------------------
Last Update Date | 12/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 880 THIRD AVE
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91911-1305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-205-4585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3814 CHEROKEE AVE APT 8
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92104-3154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-521-4989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 25432
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------