=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639275498
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACIE DAWN KENNARD OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2006
-----------------------------------------------------
Last Update Date | 07/29/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2125 ROYCE ST
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45662-4714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-876-9232
-----------------------------------------------------
Fax | 740-876-9525
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 825 DORRENE DR
-----------------------------------------------------
City | WHEELERSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45694-1824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-574-2436
-----------------------------------------------------
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 | OT-6494
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------