Provider Demographics
NPI:1437791829
Name:KENNEDY, MADELINE CLAIRE (OT/L)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:CLAIRE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 BROOKS EDGE DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-1980
Mailing Address - Country:US
Mailing Address - Phone:336-403-1537
Mailing Address - Fax:
Practice Address - Street 1:801 MEADOWOOD ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27409-2838
Practice Address - Country:US
Practice Address - Phone:336-560-8989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-17
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12617225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist