Provider Demographics
NPI:1538586391
Name:KENNEDY, CASEY (NCTMB)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 APPLE DR
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-4060
Mailing Address - Country:US
Mailing Address - Phone:970-570-6025
Mailing Address - Fax:
Practice Address - Street 1:624 APPLE DR
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-4060
Practice Address - Country:US
Practice Address - Phone:970-570-6025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-18
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10941225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist