MEDICARE: FREDERICA KENNEDY OTR/L, OTD

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	222Q00000X	Developmental Therapist
2	225X00000X	Occupational Therapist	056.006013	IL
3	225XP0200X	Pediatric Occupational Therapist	OT006737	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396958450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FREDERICA KENNEDY OTR/L, OTD

Provider Business Mailing Address
First Line	:	2791 SUMMIT VALLEY DRIVE
Second Line	:
City	:	DACULA
State	:	GA
Zip	:	30019
Country	:	US
Telephone Number	:	708-612-2881
Fax Number	:	708-283-8685

Provider Business Practice Location Address
First Line	:	2095 HIGHWAY 211 NW STE D
Second Line	:
City	:	BRASELTON
State	:	GA
Zip	:	30517-3402
Country	:	US
Telephone Number	:	770-207-6390
Fax Number	:	678-374-4855

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

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	03/17/2018

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