=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750262093
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICAELA KENNEDY PT, DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2025
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 WING DR STE 203
-----------------------------------------------------
City | CEDAR KNOLLS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07927-1024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-260-9656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 106 BRUNSWICK RD
-----------------------------------------------------
City | CEDAR GROVE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07009-1404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 40QA02372500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------