Provider Demographics
NPI:1104101617
Name:KENNEALLY, STEPHANIE A (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:KENNEALLY
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:A
Other - Last Name:BLANAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:257B MATCHAPONIX AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NJ
Mailing Address - Zip Code:08831-4034
Mailing Address - Country:US
Mailing Address - Phone:732-266-8814
Mailing Address - Fax:
Practice Address - Street 1:40 CANTERBURY DR
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-4421
Practice Address - Country:US
Practice Address - Phone:732-266-8814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-15
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR0542000171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor