=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386656205
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BROOKE ALLISON KENNEDY PT, DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2006
-----------------------------------------------------
Last Update Date | 09/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5625 PEARL DR
-----------------------------------------------------
City | EVANSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47712-8106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-759-7493
-----------------------------------------------------
Fax | 812-401-2346
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5629
-----------------------------------------------------
City | EVANSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47716-5629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-476-0409
-----------------------------------------------------
Fax | 812-476-1016
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 05009061A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 005611
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------