Provider Demographics
NPI:1356741136
Name:KENNEDY, BRADLEY (DPT)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 749306
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9306
Mailing Address - Country:US
Mailing Address - Phone:843-524-3241
Mailing Address - Fax:
Practice Address - Street 1:1510 RIBAUT RD
Practice Address - Street 2:
Practice Address - City:PORT ROYAL
Practice Address - State:SC
Practice Address - Zip Code:29935-1403
Practice Address - Country:US
Practice Address - Phone:843-524-3241
Practice Address - Fax:843-322-3240
Is Sole Proprietor?:No
Enumeration Date:2014-08-28
Last Update Date:2024-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08945R225100000X
SC8479225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist