Provider Demographics
NPI:1174139018
Name:KENNEDY, SAMUEL (LMT)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 SW 172ND TER UNIT 403
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97003-4266
Mailing Address - Country:US
Mailing Address - Phone:970-685-9515
Mailing Address - Fax:
Practice Address - Street 1:2167 NW 185TH AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-7074
Practice Address - Country:US
Practice Address - Phone:503-386-5322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25995225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist