MEDICARE: KENNEDY S FRASIER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency		KY
2	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1063113447
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNEDY S FRASIER

Provider Business Mailing Address
First Line	:	3884 DRIPPING SPRINGS RD
Second Line	:
City	:	GLASGOW
State	:	KY
Zip	:	42141-9715
Country	:	US
Telephone Number	:	270-590-5254
Fax Number	:

Provider Business Practice Location Address
First Line	:	3884 DRIPPING SPRINGS RD
Second Line	:
City	:	GLASGOW
State	:	KY
Zip	:	42141-9715
Country	:	US
Telephone Number	:	270-590-5254
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2023
Last Update Date	:	08/04/2023

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