Provider Demographics
NPI:1063763852
Name:FAHY, KENNETH P (PT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:P
Last Name:FAHY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4302 KLIMEK PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08879-2942
Mailing Address - Country:US
Mailing Address - Phone:732-925-7397
Mailing Address - Fax:
Practice Address - Street 1:4302 KLIMEK PL
Practice Address - Street 2:
Practice Address - City:SOUTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08879-2942
Practice Address - Country:US
Practice Address - Phone:732-925-7397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-20
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01453900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist