Provider Demographics
NPI:1538777214
Name:KING, KENNEDY LAINE (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:KENNEDY
Middle Name:LAINE
Last Name:KING
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 S CONGRESS AVE APT 826
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-2407
Mailing Address - Country:US
Mailing Address - Phone:614-905-1243
Mailing Address - Fax:
Practice Address - Street 1:1221 S CONGRESS AVE APT 826
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-2407
Practice Address - Country:US
Practice Address - Phone:614-905-1243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-17
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1331928225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist