MEDICARE: KIMBERLY ISABELLA KENNON OTD, OTR/L

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	225X00000X	Occupational Therapist	124590	TX

General Provider Information

NPI Number	:	1770323586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY ISABELLA KENNON OTD, OTR/L

Provider Business Mailing Address
First Line	:	2308 VILLANOVA ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76018-2551
Country	:	US
Telephone Number	:	817-862-8952
Fax Number	:

Provider Business Practice Location Address
First Line	:	5755 CLEARFORK MAIN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-3596
Country	:	US
Telephone Number	:	817-489-6602
Fax Number	:

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

Provider Enumeration Date	:	05/29/2024
Last Update Date	:	05/29/2024

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