MEDICARE: DESTINY KENNEDY DPT

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	225100000X	Physical Therapist
2	2251X0800X	Orthopedic Physical Therapist	09696	LA

General Provider Information

NPI Number	:	1205350824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINY KENNEDY DPT

Provider Business Mailing Address
First Line	:	5404 HIGHWAY 22 STE 200
Second Line	:
City	:	MANDEVILLE
State	:	LA
Zip	:	70471-2518
Country	:	US
Telephone Number	:	985-272-1017
Fax Number	:	985-272-1016

Provider Business Practice Location Address
First Line	:	5404 HIGHWAY 22 STE 200
Second Line	:
City	:	MANDEVILLE
State	:	LA
Zip	:	70471-2518
Country	:	US
Telephone Number	:	985-272-1017
Fax Number	:	985-272-1016

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

Provider Enumeration Date	:	07/26/2017
Last Update Date	:	09/03/2025

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