MEDICARE: LYDIA P KENNEBREW

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	106S00000X	Behavior Technician		KY

General Provider Information

NPI Number	:	1598681793
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYDIA P KENNEBREW

Provider Business Mailing Address
First Line	:	996 ROYAL MARCO WAY
Second Line	:
City	:	MARCO ISLAND
State	:	FL
Zip	:	34145-1829
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9110 LEESGATE RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40222-5053
Country	:	US
Telephone Number	:	502-242-9091
Fax Number	:

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

Provider Enumeration Date	:	06/24/2026
Last Update Date	:	06/24/2026

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