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General NPI Number Information
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NPI Number | 1679435408
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Entity Type | Individual
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Provider Name | KENNEDY LAKE
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Gender |
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Dates
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Enumeration Date | 12/01/2025
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Last Update Date | 12/01/2025
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Provider Practice Location Address
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Address Line | 13250 WASHINGTON AVE
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City | MOUNT PLEASANT
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State | WI
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Zip | 53177-1516
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Country | US
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Telephone | 262-799-8330
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Fax |
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Provider Business Mailing Address
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Address Line | 2704 N PROSPECT AVE
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City | MILWAUKEE
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State | WI
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Zip | 53211-3768
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State | WI
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