Provider Demographics
NPI:1366994568
Name:KENNEDY, EMILY ANASTASIA (CMT, LE)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ANASTASIA
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:CMT, LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4091 WILLIAM AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-9587
Mailing Address - Country:US
Mailing Address - Phone:317-966-4652
Mailing Address - Fax:
Practice Address - Street 1:4091 WILLIAM AVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-9587
Practice Address - Country:US
Practice Address - Phone:317-966-4652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21405075225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist